锘縣ospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|ID,"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.",,,,,,,,,,,,,,,,,,,
花千色,1/1/2025,2.2.0,花千色,"2003 花千色 Way, Coeur D'alene, ID 83814",ID,TRUE,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,billing_class,setting,drug_unit_of_measurement,drug_type_of_measurement,modifiers,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,estimated_amount,standard_charge|methodology,standard_charge|min,standard_charge|max,additional_generic_notes
"Naltrexone, depot form",0759,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1676.81,other,1676.81,1676.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Leuprolide acetate,0800,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7429.81,other,4475.27,7429.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Leuprolide acetate,0800,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4475.27,other,4475.27,7429.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Leuprolide acetate,0800,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4796.39,other,4475.27,7429.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Goserelin acetate implant,0810,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2856.66,percent of total billed charges,764.47,12234.3,
Goserelin acetate implant,0810,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4351.35,other,764.47,12234.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Goserelin acetate implant,0810,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",764.47,other,764.47,12234.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Goserelin acetate implant,0810,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2316.22,other,764.47,12234.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Goserelin acetate implant,0810,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12234.3,other,764.47,12234.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Goserelin acetate implant,0810,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2797.41,other,764.47,12234.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Synvisc or synvisc-one,0874,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",430.53,other,430.53,430.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection,onabotulinumtoxinA",0902,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2079.05,other,854.96,3251.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection,onabotulinumtoxinA",0902,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",854.96,other,854.96,3251.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection,onabotulinumtoxinA",0902,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3251.75,other,854.96,3251.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection,onabotulinumtoxinA",0902,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1401.59,other,854.96,3251.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection,onabotulinumtoxinA",0902,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1317.16,other,854.96,3251.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection,onabotulinumtoxinA",0902,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1378.75,other,854.96,3251.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Octreotide injection, depot",1207,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15439.15,other,4279.23,20151.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Octreotide injection, depot",1207,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4279.23,other,4279.23,20151.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Octreotide injection, depot",1207,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20151.85,other,4279.23,20151.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Octreotide injection, depot",1207,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16535.94,other,4279.23,20151.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Octreotide injection, depot",1207,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4319.06,other,4279.23,20151.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gel-one,1417,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",786.96,other,786.96,3103.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gel-one,1417,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3103.4,other,786.96,3103.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Visualization adjunct,1446,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2118.04,other,2118.04,2118.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Epoetin alfa, non-esrd",1686,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45.01,other,45.01,45.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Monovisc inj per dose,1747,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1775.47,other,1775.47,7273.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Monovisc inj per dose,1747,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7273.8,other,1775.47,7273.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,5911.87,percent of total billed charges,5911.87,5911.87,
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,125,301.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",175.63,other,125,301.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.37,other,125,301.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,125,301.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,301.63,percent of total billed charges,125,301.63,
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,125,301.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,125,301.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,217.53,percent of total billed charges,125,301.63,
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,125,301.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,125,301.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,267.16,percent of total billed charges,76.29,305.1,
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",80.1,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",107.06,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",195.56,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",217.29,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",77.05,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,206.45,percent of total billed charges,76.29,305.1,
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",299.95,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",76.29,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,277.64,percent of total billed charges,76.29,305.1,
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.91,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,305.1,percent of total billed charges,76.29,305.1,
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",296,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125.88,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",119.25,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",78.58,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,246.06,percent of total billed charges,76.29,305.1,
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",296,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",285.58,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",77.05,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,305.1,percent of total billed charges,76.29,305.1,
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",76.29,other,76.29,305.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,571.16,percent of total billed charges,146.18,634.65,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",157.95,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",579,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",521.1,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",402.86,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",156.34,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,372.59,percent of total billed charges,146.18,634.65,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",157.95,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",550.69,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",157.95,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,482.9,percent of total billed charges,146.18,634.65,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",513.26,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",147.21,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,516.5,percent of total billed charges,146.18,634.65,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",510.91,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",149.04,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",148.77,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",146.18,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,634.65,percent of total billed charges,146.18,634.65,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,457.31,percent of total billed charges,146.18,634.65,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",536.88,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",497.95,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",158.74,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,526.64,percent of total billed charges,146.18,634.65,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",157.2,other,146.18,634.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1585.34,percent of total billed charges,175.87,1837,
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",381.73,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1164.58,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1488.28,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1394.19,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",355.79,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1197.34,percent of total billed charges,175.87,1837,
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",275.55,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1524.04,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",357.53,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1459.5,percent of total billed charges,175.87,1837,
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1151.24,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",211.48,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,1531.02,percent of total billed charges,175.87,1837,
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1287.1,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",465.22,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",791.74,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",175.87,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",374.21,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,1144.55,percent of total billed charges,175.87,1837,
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,1451,percent of total billed charges,175.87,1837,
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1837,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1399.35,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",355.79,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1717.62,percent of total billed charges,175.87,1837,
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",363.31,other,175.87,1837,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3776.18,percent of total billed charges,354.45,4382.7,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",762.01,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1396.38,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4118.61,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3269.66,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",714.34,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2958.57,percent of total billed charges,354.45,4382.7,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1662.38,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3015.54,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",762.01,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,3561.79,percent of total billed charges,354.45,4382.7,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1689.97,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",356.86,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,3324.66,percent of total billed charges,354.45,4382.7,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2840.72,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",762.01,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1317.8,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",354.45,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",773.5,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,4354.34,percent of total billed charges,354.45,4382.7,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,3090.88,percent of total billed charges,354.45,4382.7,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1033.31,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3160.01,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3494.44,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",680.75,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,4382.7,percent of total billed charges,354.45,4382.7,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",743.69,other,354.45,4382.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,6148.76,percent of total billed charges,496.36,7547.16,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2077.19,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2455.76,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5742.13,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5991.23,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1188.51,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,5407.65,percent of total billed charges,496.36,7547.16,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4694.5,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1309.08,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,6494.26,percent of total billed charges,496.36,7547.16,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",496.36,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,7382.69,percent of total billed charges,496.36,7547.16,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4326.5,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1249.12,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2593.93,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",529.29,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1567.87,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,5760.06,percent of total billed charges,496.36,7547.16,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,2497.71,percent of total billed charges,496.36,7547.16,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1197.63,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5032.62,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7547.16,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1208.78,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,6308.53,percent of total billed charges,496.36,7547.16,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1371.94,other,496.36,7547.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,7829.11,percent of total billed charges,663.25,11609.6,
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2477.95,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9932.34,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10528.69,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5760.67,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2593.86,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,4698.46,percent of total billed charges,663.25,11609.6,
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2477.95,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6858.11,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2560.73,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,11609.6,percent of total billed charges,663.25,11609.6,
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",663.25,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,9702.5,percent of total billed charges,663.25,11609.6,
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3718.4,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",805.57,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2826.03,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,11569.27,percent of total billed charges,663.25,11609.6,
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7822.29,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1794.24,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,9421.29,percent of total billed charges,663.25,11609.6,
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2643.51,other,663.25,11609.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,15471.59,percent of total billed charges,2525.46,28993.91,
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2780.59,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28993.91,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5620.58,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10573.98,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2987.52,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,11812.24,percent of total billed charges,2525.46,28993.91,
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13046.5,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3696.15,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,19447.32,percent of total billed charges,2525.46,28993.91,
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22118.08,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,15383.59,percent of total billed charges,2525.46,28993.91,
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7109,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6628.74,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5999.9,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3214.86,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,20880.1,percent of total billed charges,2525.46,28993.91,
Trauma Response with Critical Care,5045,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2525.46,other,2525.46,28993.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1043.93,percent of total billed charges,126.37,2246.35,
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",313.74,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",645.99,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1270.16,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",821.34,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.37,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,715.3,percent of total billed charges,126.37,2246.35,
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1357.18,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",189,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,2246.35,percent of total billed charges,126.37,2246.35,
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",311.18,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",510.91,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",222.72,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",142.81,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",142.82,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1955.25,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1077.62,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",128.95,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1119.42,percent of total billed charges,126.37,2246.35,
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,126.37,2246.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1226.77,percent of total billed charges,109.13,5248.15,
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",549,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3603.67,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",507.53,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2809.8,percent of total billed charges,109.13,5248.15,
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2030.66,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",575.08,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1123.28,percent of total billed charges,109.13,5248.15,
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",109.13,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,5248.15,percent of total billed charges,109.13,5248.15,
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1673.75,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1995,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",374.42,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",607,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,912.12,percent of total billed charges,109.13,5248.15,
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4676.92,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",503.69,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3238.89,percent of total billed charges,109.13,5248.15,
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",577.64,other,109.13,5248.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",852.64,other,219.26,3186.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1547.98,other,219.26,3186.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",705.99,other,219.26,3186.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1789.06,percent of total billed charges,219.26,3186.56,
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2525.42,other,219.26,3186.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,3186.56,percent of total billed charges,219.26,3186.56,
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1509,other,219.26,3186.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",219.26,other,219.26,3186.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",864.34,other,219.26,3186.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",804.26,other,219.26,3186.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",799.1,other,219.26,3186.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7438.08,other,1171.1,7644.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1746.73,other,1171.1,7644.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5267.48,other,1171.1,7644.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1753.4,other,1171.1,7644.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6856,other,1171.1,7644.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6274.67,other,1171.1,7644.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7644.18,other,1171.1,7644.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2596.3,other,1171.1,7644.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1171.1,other,1171.1,7644.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3568.76,other,3568.76,3568.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hyperbaric Oxygen,5061,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11616,other,5756.09,11616,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hyperbaric Oxygen,5061,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5756.09,other,5756.09,11616,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hyperbaric Oxygen,5061,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,9832.63,percent of total billed charges,5756.09,11616,
Hyperbaric Oxygen,5061,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7431.46,other,5756.09,11616,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1514.25,percent of total billed charges,665.92,2373.58,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1155,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1540.61,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1641.96,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1379.14,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",678.55,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1094.44,percent of total billed charges,665.92,2373.58,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1824.4,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",679.49,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1403.74,percent of total billed charges,665.92,2373.58,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,1419.51,percent of total billed charges,665.92,2373.58,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2373.58,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",679.11,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1528.74,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",665.92,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1347.4,percent of total billed charges,665.92,2373.58,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",679.49,other,665.92,2373.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3264.64,percent of total billed charges,943.9,11043.06,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1599.65,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4912.12,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3221.68,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1556.82,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,3020.93,percent of total billed charges,943.9,11043.06,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3552.4,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1593.54,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,4427.42,percent of total billed charges,943.9,11043.06,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1904.35,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,2072.61,percent of total billed charges,943.9,11043.06,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2926.7,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3288.16,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",943.9,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1602.61,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,2803.5,percent of total billed charges,943.9,11043.06,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11043.06,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4786.12,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1601.5,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3162.33,percent of total billed charges,943.9,11043.06,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1565.79,other,943.9,11043.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,4855.72,percent of total billed charges,493.24,13073.6,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2744.22,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8547,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11542.82,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8098.27,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2718.98,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,6174.05,percent of total billed charges,493.24,13073.6,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9958.1,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2684.35,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,9586.88,percent of total billed charges,493.24,13073.6,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1606.51,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,5173.45,percent of total billed charges,493.24,13073.6,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",493.24,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3131.82,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13073.6,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2730.21,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,7130.78,percent of total billed charges,493.24,13073.6,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2716.48,other,493.24,13073.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3720.12,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11160.12,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3541.87,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,7900.82,percent of total billed charges,3541.87,26290.04,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15376.36,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4934.83,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,12784.47,percent of total billed charges,3541.87,26290.04,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14462.05,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3597.45,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26290.04,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3797.89,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,20437.86,percent of total billed charges,3541.87,26290.04,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3626.52,other,3541.87,26290.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,26150.37,percent of total billed charges,6038,26532.18,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6038,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19298.58,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6061.23,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,21025.87,percent of total billed charges,6038,26532.18,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26532.18,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6376.9,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,25658.42,percent of total billed charges,6038,26532.18,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22952.19,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21736.8,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6188.98,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18378.83,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6416.02,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,24938.88,percent of total billed charges,6038,26532.18,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6297.86,other,6038,26532.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31483.39,other,31483.39,31483.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25539.92,other,25539.92,66461.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",66461.16,other,25539.92,66461.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2287.85,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1470.64,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",529.73,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3994.66,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",590.57,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3420.16,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",285.21,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",614.51,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,2497.07,percent of total billed charges,285.21,3994.66,
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2798.58,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",536.24,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",837.94,other,285.21,3994.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",253,other,253,2608.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1013.52,other,253,2608.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1923.48,other,253,2608.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",989.23,other,253,2608.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2608.84,other,253,2608.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Strapping and Cast Application,5102,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",734.13,other,253,2608.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1053.27,percent of total billed charges,238.24,26563.99,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",862.5,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26563.99,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1142.1,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2412.32,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",238.24,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,6234.87,percent of total billed charges,238.24,26563.99,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2824.9,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,2164.06,percent of total billed charges,238.24,26563.99,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",690,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2256.11,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1047.32,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",391.42,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,2090.58,percent of total billed charges,238.24,26563.99,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2778.65,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",547.92,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,2960.87,percent of total billed charges,238.24,26563.99,
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",511.3,other,238.24,26563.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,4700.7,percent of total billed charges,998.64,9981.18,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1552.19,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1535.65,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5525.59,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5845.99,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1461.01,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,3754.66,percent of total billed charges,998.64,9981.18,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5759.74,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1457.41,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,5715.3,percent of total billed charges,998.64,9981.18,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4449.48,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1457.41,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",998.64,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1567.48,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,5827.55,percent of total billed charges,998.64,9981.18,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9981.18,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1567.71,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,4546.85,percent of total billed charges,998.64,9981.18,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1552.19,other,998.64,9981.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,6922.64,percent of total billed charges,3000.32,33680.65,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3126.03,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12830.35,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6972.35,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7772.43,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3000.32,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,4621.49,percent of total billed charges,3000.32,33680.65,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10608.1,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3024.17,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,8779.69,percent of total billed charges,3000.32,33680.65,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,33680.65,percent of total billed charges,3000.32,33680.65,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11096.9,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3388.88,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3168.29,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,8914.62,percent of total billed charges,3000.32,33680.65,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6929.91,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3174.49,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,10206.91,percent of total billed charges,3000.32,33680.65,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3116.17,other,3000.32,33680.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,32948.06,percent of total billed charges,3336.46,32948.06,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6910.44,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24232.63,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20386.73,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6751.93,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,18792.04,percent of total billed charges,3336.46,32948.06,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25919.8,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6909.17,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,28155.96,percent of total billed charges,3336.46,32948.06,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3336.46,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,23206.48,percent of total billed charges,3336.46,32948.06,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24873.01,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6831.6,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3837.43,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7106.69,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,6850.07,percent of total billed charges,3336.46,32948.06,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,18899.74,percent of total billed charges,3336.46,32948.06,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21543.24,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6978.26,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,24796.43,percent of total billed charges,3336.46,32948.06,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6899.7,other,3336.46,32948.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,51462.74,percent of total billed charges,3388.88,52028.93,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13352.08,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31520.38,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44615.31,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43513.86,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13131.5,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,39003.39,percent of total billed charges,3388.88,52028.93,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",52028.93,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13390.26,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,50468.09,percent of total billed charges,3388.88,52028.93,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16007.14,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3388.88,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,45985.1,percent of total billed charges,3388.88,52028.93,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",46094.98,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5790.76,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13923.33,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,40027.76,percent of total billed charges,3388.88,52028.93,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,29163.22,percent of total billed charges,3388.88,52028.93,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22371.05,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13233.39,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,50257.61,percent of total billed charges,3388.88,52028.93,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13256.33,other,3388.88,52028.93,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43094.92,other,17953.09,54084.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17953.09,other,17953.09,54084.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51737.86,other,17953.09,54084.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17998.12,other,17953.09,54084.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30276.61,other,17953.09,54084.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18336.27,other,17953.09,54084.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18368.89,other,17953.09,54084.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,54084.01,percent of total billed charges,17953.09,54084.01,
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18057.57,other,17953.09,54084.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",298,other,173,3260.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",173,other,173,3260.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",301.29,other,173,3260.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",318.97,other,173,3260.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",453.48,other,173,3260.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",225.63,other,173,3260.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1133.83,other,173,3260.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",298,other,173,3260.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3260.8,percent of total billed charges,173,3260.8,
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",298,other,173,3260.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,11243.39,percent of total billed charges,1047.45,11243.39,
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1624.07,other,1047.45,11243.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1047.45,other,1047.45,11243.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3393.02,other,1047.45,11243.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1627.45,other,1047.45,11243.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,4963.78,percent of total billed charges,1047.45,11243.39,
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5131.24,other,1047.45,11243.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1624.07,other,1047.45,11243.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,5483.48,percent of total billed charges,1047.45,11243.39,
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6110.26,other,1047.45,11243.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1655.56,other,1047.45,11243.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1624.07,other,1047.45,11243.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,6720.71,percent of total billed charges,3359.32,13298.19,
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3523.59,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13298.19,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11609.15,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3359.32,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,8378.86,percent of total billed charges,3359.32,13298.19,
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12928.56,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3501.76,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,7400.71,percent of total billed charges,3359.32,13298.19,
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3488.47,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6826.88,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3393.72,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3616.65,other,3359.32,13298.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,13512.08,percent of total billed charges,2173.22,19872,
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8660,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2173.22,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19872,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14087.19,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6286.7,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,11448.81,percent of total billed charges,2173.22,19872,
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19229.88,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6285.83,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,8687.85,percent of total billed charges,2173.22,19872,
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6808.31,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6676.11,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,17184.99,percent of total billed charges,2173.22,19872,
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6610.01,other,2173.22,19872,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1455.12,percent of total billed charges,347,3297.61,
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1157.58,other,347,3297.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",390.6,other,347,3297.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,3297.61,percent of total billed charges,347,3297.61,
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",880.92,other,347,3297.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1716.64,percent of total billed charges,347,3297.61,
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1062.75,other,347,3297.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",359.22,other,347,3297.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",347,other,347,3297.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1285.51,percent of total billed charges,347,3297.61,
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",393.21,other,347,3297.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3307.4,other,553.43,6213.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1525.14,other,553.43,6213.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",553.43,other,553.43,6213.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6213.12,other,553.43,6213.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",586.9,other,553.43,6213.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",573.16,other,553.43,6213.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",580.91,other,553.43,6213.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,2364.12,percent of total billed charges,553.43,6213.12,
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",586.9,other,553.43,6213.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1472.84,other,1395.9,4923.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4898.86,other,1395.9,4923.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1395.9,other,1395.9,4923.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,3759.2,percent of total billed charges,1395.9,4923.29,
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4923.29,other,1395.9,4923.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1410.29,other,1395.9,4923.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1441.56,other,1395.9,4923.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,10229.69,percent of total billed charges,3202.68,11568.42,
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7487.41,other,3202.68,11568.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4408.03,other,3202.68,11568.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11568.42,other,3202.68,11568.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,9923.89,percent of total billed charges,3202.68,11568.42,
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3202.68,other,3202.68,11568.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10476.68,other,3202.68,11568.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,8882.5,percent of total billed charges,3202.68,11568.42,
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,18263.73,percent of total billed charges,159.3,29449.68,
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18711.29,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11019.83,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5604.27,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,6710.74,percent of total billed charges,159.3,29449.68,
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12230.87,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5655.71,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,29449.68,percent of total billed charges,159.3,29449.68,
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",159.3,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5424.89,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2116.26,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,6750.52,percent of total billed charges,159.3,29449.68,
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5838.67,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,9570.12,percent of total billed charges,159.3,29449.68,
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5550.5,other,159.3,29449.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",617.12,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1281.37,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1430.01,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",607.51,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1343.09,percent of total billed charges,597.22,8620.8,
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2205.4,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",597.22,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1997.7,percent of total billed charges,597.22,8620.8,
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",635.75,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",615.13,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8620.8,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",644.44,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,2163.4,percent of total billed charges,597.22,8620.8,
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",606.7,other,597.22,8620.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3724.9,percent of total billed charges,635.75,26219.29,
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1546.71,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13671.91,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3580.15,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1502.69,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,3216.92,percent of total billed charges,635.75,26219.29,
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4378.1,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1546.71,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,4118.88,percent of total billed charges,635.75,26219.29,
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",635.75,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4220.2,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",635.75,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1556.95,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26219.29,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2991.9,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1532.33,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3762.49,percent of total billed charges,635.75,26219.29,
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1546.71,other,635.75,26219.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,10954.27,percent of total billed charges,3006.53,12876.17,
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3082.3,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8879.36,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10256.62,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3006.53,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,8078.14,percent of total billed charges,3006.53,12876.17,
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11855.92,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3078.37,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,12876.17,percent of total billed charges,3006.53,12876.17,
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3788.05,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12130.34,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3264.54,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3135.92,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6211.08,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10808.01,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3060.75,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,11666.22,percent of total billed charges,3006.53,12876.17,
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3030.44,other,3006.53,12876.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5307.23,other,5178.92,25095.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16161.84,other,5178.92,25095.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13266.2,other,5178.92,25095.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5178.92,other,5178.92,25095.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,11649.56,percent of total billed charges,5178.92,25095.54,
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19764.66,other,5178.92,25095.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5246.76,other,5178.92,25095.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,25095.54,percent of total billed charges,5178.92,25095.54,
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10188.39,other,5178.92,25095.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5221.79,other,5178.92,25095.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,24378.35,percent of total billed charges,5178.92,25095.54,
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5289.01,other,5178.92,25095.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,15295.56,percent of total billed charges,1550.12,20816.98,
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3150.95,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20816.98,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12182.82,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3118.81,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,13390.68,percent of total billed charges,1550.12,20816.98,
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12240.47,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3150.95,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,17280.78,percent of total billed charges,1550.12,20816.98,
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,18539.61,percent of total billed charges,1550.12,20816.98,
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14989.52,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2954.42,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1550.12,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3243.46,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,15800.44,percent of total billed charges,1550.12,20816.98,
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16531.72,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3125.81,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,18299.79,percent of total billed charges,1550.12,20816.98,
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3133.49,other,1550.12,20816.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,21178.03,percent of total billed charges,5255.24,25372.02,
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14279.84,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13152.74,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13916.38,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5255.24,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,16245.56,percent of total billed charges,5255.24,25372.02,
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16777.02,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5521.98,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,25372.02,percent of total billed charges,5255.24,25372.02,
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6782.06,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5386.98,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20687.57,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5287.34,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5520.01,other,5255.24,25372.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,11710.52,percent of total billed charges,10681.23,65596.04,
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11060.44,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",47807.38,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31101.07,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10681.23,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,32867.74,percent of total billed charges,10681.23,65596.04,
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51017.52,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10788.66,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,65596.04,percent of total billed charges,10681.23,65596.04,
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38262.59,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20612.47,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10752.32,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,53206.04,percent of total billed charges,10681.23,65596.04,
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10788.66,other,10681.23,65596.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,59534.01,percent of total billed charges,5739.52,67089.29,
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43420.71,other,5739.52,67089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11643.84,other,5739.52,67089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",67089.29,other,5739.52,67089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17455.68,other,5739.52,67089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5739.52,other,5739.52,67089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17455.68,other,5739.52,67089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,44791.65,percent of total billed charges,5739.52,67089.29,
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17123.4,other,5739.52,67089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,16952.18,percent of total billed charges,5739.52,67089.29,
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16936.82,other,5739.52,67089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electrophysiologic Procedures,5211,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1144.66,other,1144.66,1144.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7216.46,other,6780.82,36247.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25734.32,other,6780.82,36247.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6780.82,other,6780.82,36247.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25221.35,other,6780.82,36247.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,10189.82,percent of total billed charges,6780.82,36247.94,
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15876.8,other,6780.82,36247.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9281.48,other,6780.82,36247.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,36247.94,percent of total billed charges,6780.82,36247.94,
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7084.9,other,6780.82,36247.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,83460.65,percent of total billed charges,9038.25,89029.9,
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22986.4,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",55053.88,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56310.84,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22714.32,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,55704.31,percent of total billed charges,9038.25,89029.9,
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",89029.9,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22941.33,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,51677.21,percent of total billed charges,9038.25,89029.9,
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29824.97,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,83799.32,percent of total billed charges,9038.25,89029.9,
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",85623.32,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24571.73,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,9038.25,percent of total billed charges,9038.25,89029.9,
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",59871.42,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23411.02,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,83986.69,percent of total billed charges,9038.25,89029.9,
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23054.78,other,9038.25,89029.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,27812.78,percent of total billed charges,8204.86,33422.18,
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8248.96,other,8204.86,33422.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18108.73,other,8204.86,33422.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8214.96,other,8204.86,33422.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,19931.08,percent of total billed charges,8204.86,33422.18,
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32014.2,other,8204.86,33422.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8204.86,other,8204.86,33422.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,25027.67,percent of total billed charges,8204.86,33422.18,
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8293.05,other,8204.86,33422.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33422.18,other,8204.86,33422.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8215.46,other,8204.86,33422.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,27016.38,percent of total billed charges,8204.86,33422.18,
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8211.56,other,8204.86,33422.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10807.88,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16312.8,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10217.51,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,33068.73,percent of total billed charges,10217.51,42404.46,
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35695.04,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10493.62,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42404.46,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11159.26,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32489.72,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10410.03,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,24809.07,percent of total billed charges,10217.51,42404.46,
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10316.66,other,10217.51,42404.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29562.68,other,18786.42,86398.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18786.42,other,18786.42,86398.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",64732.38,other,18786.42,86398.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18898.04,other,18786.42,86398.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18821.37,other,18786.42,86398.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,35846.27,percent of total billed charges,18786.42,86398.99,
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",86398.99,other,18786.42,86398.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23182.5,other,22768.47,77025.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22956.43,other,22768.47,77025.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40485.18,other,22768.47,77025.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23186.43,other,22768.47,77025.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,59757.41,percent of total billed charges,22768.47,77025.61,
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,72676.91,percent of total billed charges,22768.47,77025.61,
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",77025.61,other,22768.47,77025.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23026.94,other,22768.47,77025.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,72464.09,percent of total billed charges,22768.47,77025.61,
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22768.47,other,22768.47,77025.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,62631.08,percent of total billed charges,31458.72,114396.61,
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31776.84,other,31458.72,114396.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",63440.81,other,31458.72,114396.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",61601.5,other,31458.72,114396.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31458.72,other,31458.72,114396.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",93294.14,other,31458.72,114396.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32592.2,other,31458.72,114396.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,109991.39,percent of total billed charges,31458.72,114396.61,
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",114396.61,other,31458.72,114396.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32129.98,other,31458.72,114396.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,93981.15,percent of total billed charges,31458.72,114396.61,
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32592.2,other,31458.72,114396.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2960.56,percent of total billed charges,621.58,3091.9,
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1041.62,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2571.66,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2745.91,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",666.51,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2260.96,percent of total billed charges,621.58,3091.9,
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2149,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3059.82,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",909.6,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2811.16,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",621.58,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3091.9,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",796.86,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,2630.17,percent of total billed charges,621.58,3091.9,
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",814.35,other,621.58,3091.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11373.77,other,11373.77,11373.77,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2882.14,percent of total billed charges,610.22,3346.05,
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",875.45,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",610.22,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2612.06,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2368.74,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",837.39,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2128.7,percent of total billed charges,610.22,3346.05,
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3346.05,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",875.45,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,2902.59,percent of total billed charges,610.22,3346.05,
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",887.32,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,2965.72,percent of total billed charges,610.22,3346.05,
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3085.45,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",862.44,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1045.97,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",901.71,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,2734.87,percent of total billed charges,610.22,3346.05,
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,1807.39,percent of total billed charges,610.22,3346.05,
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1050.54,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2685.66,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",884.2,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3141.28,percent of total billed charges,610.22,3346.05,
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",875.45,other,610.22,3346.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3227.72,percent of total billed charges,704.2,5524.17,
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1837.68,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3915.22,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3490.54,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1758.59,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2876.86,percent of total billed charges,704.2,5524.17,
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4765.2,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1769.39,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,3645.54,percent of total billed charges,704.2,5524.17,
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,3991.7,percent of total billed charges,704.2,5524.17,
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5524.17,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",704.2,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1862.52,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,3626.5,percent of total billed charges,704.2,5524.17,
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,3659.17,percent of total billed charges,704.2,5524.17,
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2209.93,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4718.07,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1856.06,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,4011.62,percent of total billed charges,704.2,5524.17,
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1828.04,other,704.2,5524.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,9984.18,percent of total billed charges,2812.73,16412.89,
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9401.94,other,2812.73,16412.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3285.94,other,2812.73,16412.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,9423.07,percent of total billed charges,2812.73,16412.89,
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16412.89,other,2812.73,16412.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3698.66,other,2812.73,16412.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2812.73,other,2812.73,16412.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3809.62,other,2812.73,16412.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,8318.3,percent of total billed charges,2812.73,16412.89,
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,8616.05,percent of total billed charges,2812.73,16412.89,
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10463.21,other,2812.73,16412.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3318.74,other,2812.73,16412.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,10657.11,percent of total billed charges,2812.73,16412.89,
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3698.66,other,2812.73,16412.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3275.64,percent of total billed charges,619.34,4419.85,
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",882.67,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",619.34,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3566.88,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2127.96,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",873.67,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2470.33,percent of total billed charges,619.34,4419.85,
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3327.02,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",844.3,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,3259.49,percent of total billed charges,619.34,4419.85,
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1103.34,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,3125.66,percent of total billed charges,619.34,4419.85,
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3177.61,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2771.68,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4419.85,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",668.88,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",890.97,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,3058.58,percent of total billed charges,619.34,4419.85,
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,2093.67,percent of total billed charges,619.34,4419.85,
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3291.81,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",873.67,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3581.87,percent of total billed charges,619.34,4419.85,
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",882.67,other,619.34,4419.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3417.69,percent of total billed charges,919.8,4333.72,
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1155.2,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4333.72,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3619.26,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2629.42,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1128.05,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2635.43,percent of total billed charges,919.8,4333.72,
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4288.13,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1139.67,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,3475.18,percent of total billed charges,919.8,4333.72,
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1424.59,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,3627.23,percent of total billed charges,919.8,4333.72,
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4102.81,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3573.72,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2792.18,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",919.8,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1542.34,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,3592.09,percent of total billed charges,919.8,4333.72,
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,2968.15,percent of total billed charges,919.8,4333.72,
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3504.68,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1151.07,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3936.28,percent of total billed charges,919.8,4333.72,
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1139.67,other,919.8,4333.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,12345.76,percent of total billed charges,2711.68,12644.72,
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9403.42,other,2711.68,12644.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2739.39,other,2711.68,12644.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,8029.63,percent of total billed charges,2711.68,12644.72,
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12644.72,other,2711.68,12644.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2715.87,other,2711.68,12644.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,7898.85,percent of total billed charges,2711.68,12644.72,
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2738.8,other,2711.68,12644.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,9823.97,percent of total billed charges,2711.68,12644.72,
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2711.68,other,2711.68,12644.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,36911.22,percent of total billed charges,3363.5,36911.22,
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5324.36,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13164.66,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5277.05,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,11573.39,percent of total billed charges,3363.5,36911.22,
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20345.18,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5504.15,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,19373.88,percent of total billed charges,3363.5,36911.22,
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14922.36,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3363.5,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5311.02,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,17757.99,percent of total billed charges,3363.5,36911.22,
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18376.42,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,16687.55,percent of total billed charges,3363.5,36911.22,
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16745.45,other,3363.5,36911.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,11112.36,percent of total billed charges,3313.66,14094.67,
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3598.46,other,3313.66,14094.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14094.67,other,3313.66,14094.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3313.66,other,3313.66,14094.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,10696.22,percent of total billed charges,3313.66,14094.67,
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13282.63,other,3313.66,14094.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3345.17,other,3313.66,14094.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3408.15,other,3313.66,14094.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3341.24,other,3313.66,14094.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,21548.06,percent of total billed charges,2747.46,22986.54,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5572.47,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18504.78,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15950.41,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16791.82,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5522.63,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,15274.29,percent of total billed charges,2747.46,22986.54,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21439.34,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5641.47,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,18627.11,percent of total billed charges,2747.46,22986.54,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6965.59,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,19209.18,percent of total billed charges,2747.46,22986.54,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19063.22,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8737.31,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2747.46,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5454.2,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,22986.54,percent of total billed charges,2747.46,22986.54,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,4099.4,percent of total billed charges,2747.46,22986.54,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18830.73,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18615.68,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5628.19,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,20562.83,percent of total billed charges,2747.46,22986.54,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5572.47,other,2747.46,22986.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,26248.71,percent of total billed charges,9586.84,33111.53,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9586.84,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24219.5,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23927.74,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9845.68,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,18980.97,percent of total billed charges,9586.84,33111.53,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33111.53,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9954.16,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,25253.36,percent of total billed charges,9586.84,33111.53,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,31173.9,percent of total billed charges,9586.84,33111.53,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21754.54,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19387.89,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9874.44,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,21483.68,percent of total billed charges,9586.84,33111.53,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,30326.67,percent of total billed charges,9586.84,33111.53,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21972.84,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10058.38,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,27911.8,percent of total billed charges,9586.84,33111.53,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9941.34,other,9586.84,33111.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,669.32,percent of total billed charges,340.78,1479,
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",881.22,other,340.78,1479,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",340.78,other,340.78,1479,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1479,other,340.78,1479,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",390.91,other,340.78,1479,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",635.32,other,635.32,1466.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1466.95,other,635.32,1466.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",639.73,other,635.32,1466.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",659.72,other,635.32,1466.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,12670.7,percent of total billed charges,131.82,13780.51,
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1927.75,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13780.51,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9062.53,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1877.12,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,131.82,percent of total billed charges,131.82,13780.51,
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2118,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7184.95,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1967.09,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3507.48,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1941.01,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9959.62,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2021.16,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,6077.85,percent of total billed charges,131.82,13780.51,
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1951.37,other,131.82,13780.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,12013.66,percent of total billed charges,3191.14,21252.99,
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3419.08,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21252.99,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9165.02,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10169.86,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3230.55,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,7623.62,percent of total billed charges,3191.14,21252.99,
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12096.79,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3366.82,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,9969.2,percent of total billed charges,3191.14,21252.99,
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,9892.4,percent of total billed charges,3191.14,21252.99,
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12120.55,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3191.14,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3467.82,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,17863.14,percent of total billed charges,3191.14,21252.99,
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7478.97,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3385.52,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,12357.36,percent of total billed charges,3191.14,21252.99,
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3366.82,other,3191.14,21252.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,16131.36,percent of total billed charges,4735.5,17456.76,
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4997.23,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13549.1,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4735.5,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,11477.97,percent of total billed charges,4735.5,17456.76,
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17171.4,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4997.23,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,13976.2,percent of total billed charges,4735.5,17456.76,
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17198.02,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4777.23,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,17456.76,percent of total billed charges,4735.5,17456.76,
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13318.75,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5080.7,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,15719.56,percent of total billed charges,4735.5,17456.76,
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4997.23,other,4735.5,17456.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9003.46,other,9003.46,36118.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22672.76,other,9003.46,36118.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36118.22,other,9003.46,36118.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9014.93,other,9003.46,36118.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45661.34,other,19574.34,78684.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",78684.55,other,19574.34,78684.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19574.34,other,19574.34,78684.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2738.16,other,2592.64,7513.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7193.91,other,2592.64,7513.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7513.83,other,2592.64,7513.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,2592.64,percent of total billed charges,2592.64,7513.83,
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2699.78,other,2592.64,7513.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,983.55,percent of total billed charges,117.53,1251.71,
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",304,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1133.1,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",612.12,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",300.66,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,749.28,percent of total billed charges,117.53,1251.71,
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1251.71,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",303.76,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1096,percent of total billed charges,117.53,1251.71,
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,1135,percent of total billed charges,117.53,1251.71,
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1162.02,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1092.53,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",117.53,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",312.87,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,892.42,percent of total billed charges,117.53,1251.71,
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,490.56,percent of total billed charges,117.53,1251.71,
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1185,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1032.52,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",297.92,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1133.1,percent of total billed charges,117.53,1251.71,
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",303.76,other,117.53,1251.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,245.68,percent of total billed charges,178,555.24,
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",178,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",266.4,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",296,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",390.94,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,250.3,percent of total billed charges,178,555.24,
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",296,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",303.22,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,266.4,percent of total billed charges,178,555.24,
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",296,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",296,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",555.24,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",378.72,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,266.4,percent of total billed charges,178,555.24,
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",307.78,other,178,555.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",776.39,other,774.2,2603.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2603.78,other,774.2,2603.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",828.95,other,774.2,2603.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",809.38,other,774.2,2603.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",774.2,other,774.2,2603.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",945.24,other,774.2,2603.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,12030.41,percent of total billed charges,444.13,12030.41,
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3020.92,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9029.21,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8591.74,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2995.04,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,7328.4,percent of total billed charges,444.13,12030.41,
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11014.57,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2964.57,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,8406.98,percent of total billed charges,444.13,12030.41,
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,7555.37,percent of total billed charges,444.13,12030.41,
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",444.13,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3109.92,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,4701.44,percent of total billed charges,444.13,12030.41,
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8182.98,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2975.77,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,10603.25,percent of total billed charges,444.13,12030.41,
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3019.34,other,444.13,12030.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,17530.08,percent of total billed charges,4714.11,19554.96,
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4803.65,other,4714.11,19554.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14587.56,other,4714.11,19554.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13984.98,other,4714.11,19554.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4714.11,other,4714.11,19554.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,11305.66,percent of total billed charges,4714.11,19554.96,
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16273.71,other,4714.11,19554.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4803.65,other,4714.11,19554.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,13537.86,percent of total billed charges,4714.11,19554.96,
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4947.76,other,4714.11,19554.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19554.96,other,4714.11,19554.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,16064.43,percent of total billed charges,4714.11,19554.96,
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4756.37,other,4714.11,19554.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14285.58,other,7102.74,28460.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28157.8,other,7102.74,28460.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7128.09,other,7102.74,28460.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,15407.95,percent of total billed charges,7102.74,28460.61,
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28460.61,other,7102.74,28460.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7438.29,other,7102.74,28460.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7102.74,other,7102.74,28460.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,12139.84,percent of total billed charges,917.97,12139.84,
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1864.69,other,917.97,12139.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6502.42,other,917.97,12139.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1828.12,other,917.97,12139.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9805.42,other,917.97,12139.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1864.69,other,917.97,12139.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",917.97,other,917.97,12139.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1883.34,other,917.97,12139.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1826.21,other,917.97,12139.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15194.69,other,15194.69,19161.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Procedures,5432,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19161.58,other,15194.69,19161.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1129.71,percent of total billed charges,290.53,2410.13,
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",413.71,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1759.5,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1067.59,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1046.51,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",409.49,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,868.52,percent of total billed charges,290.53,2410.13,
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1230.26,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1080.39,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",413.71,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1569.66,percent of total billed charges,290.53,2410.13,
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",701.99,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",314.21,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,2410.13,percent of total billed charges,290.53,2410.13,
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1518.13,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1054.22,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",290.53,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",485.67,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,1027.58,percent of total billed charges,290.53,2410.13,
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,443.99,percent of total billed charges,290.53,2410.13,
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1101.83,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",417.85,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1403.56,percent of total billed charges,290.53,2410.13,
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",413.71,other,290.53,2410.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2989.53,percent of total billed charges,545.69,8840.45,
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",991.9,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8840.45,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2689.97,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1139.13,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2167.03,percent of total billed charges,545.69,8840.45,
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3102.62,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1941.99,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,2350.57,percent of total billed charges,545.69,8840.45,
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",818.28,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5097.08,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2106.88,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",545.69,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1328.48,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3364.07,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2541.3,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,5046.66,percent of total billed charges,545.69,8840.45,
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1282.12,other,545.69,8840.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1656.02,other,1656.02,1656.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,11878.24,percent of total billed charges,11878.24,11878.24,
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6605.03,other,6605.03,6605.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19133.27,other,8179.88,21429.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8179.88,other,8179.88,21429.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21429.99,other,8179.88,21429.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20965.4,other,8179.88,21429.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",95683.59,other,29827.04,121775.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",121775.52,other,29827.04,121775.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29827.04,other,29827.04,121775.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Implantation of Drug Infusion Device,5471,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18957.82,other,6841.94,18957.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Implantation of Drug Infusion Device,5471,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6841.94,other,6841.94,18957.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Implantation of Drug Infusion Device,5471,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17482.96,other,6841.94,18957.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Intraocular Procedures,5493,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13403.53,other,13403.53,13403.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",289.78,other,289.78,289.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2348.8,other,2147.96,7681.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5505.19,other,2147.96,7681.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7681.37,other,2147.96,7681.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures",5503,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2147.96,other,2147.96,7681.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures",5504,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11136.13,other,11136.13,11136.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,233.23,percent of total billed charges,37.72,571.16,
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",92.68,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",244,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",265,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",233.21,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",87.77,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,171.13,percent of total billed charges,37.72,571.16,
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",210.66,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",88.27,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,265.44,percent of total billed charges,37.72,571.16,
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",109.7,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",54.79,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,312.3,percent of total billed charges,37.72,571.16,
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",281,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37.72,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",309.3,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38.21,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",91.91,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,222.43,percent of total billed charges,37.72,571.16,
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,213.86,percent of total billed charges,37.72,571.16,
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",571.16,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",371,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",265.44,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",88.64,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,241.2,percent of total billed charges,37.72,571.16,
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",88.27,other,37.72,571.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,435.75,percent of total billed charges,70.56,550,
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",108.59,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",282,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",473.85,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",478.56,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",107.49,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,334.95,percent of total billed charges,70.56,550,
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",283.53,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",108.59,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,494.68,percent of total billed charges,70.56,550,
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",134.24,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",70.56,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,507.6,percent of total billed charges,70.56,550,
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",382.24,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",231.38,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",228.04,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",81.81,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",111.85,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,413.08,percent of total billed charges,70.56,550,
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,321.36,percent of total billed charges,70.56,550,
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",550,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",475.64,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",107.49,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,479.7,percent of total billed charges,70.56,550,
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",108.59,other,70.56,550,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1462.46,percent of total billed charges,169.95,2350,
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",236.65,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",474.8,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1431.58,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1473.34,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",238.24,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1110.06,percent of total billed charges,169.95,2350,
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",599.25,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",237.25,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1480.08,percent of total billed charges,169.95,2350,
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",296.56,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,1585.8,percent of total billed charges,169.95,2350,
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",854.1,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",236.42,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",496.97,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",169.95,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",244.37,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,1430.65,percent of total billed charges,169.95,2350,
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,332.15,percent of total billed charges,169.95,2350,
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2350,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1476.64,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",239.02,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1585.8,percent of total billed charges,169.95,2350,
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",236.65,other,169.95,2350,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1193.54,percent of total billed charges,369.26,2025.74,
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",532.79,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1818.7,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1294.2,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1438,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",506.54,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,905.94,percent of total billed charges,369.26,2025.74,
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1438,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2025.74,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",532.79,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1207.92,percent of total billed charges,369.26,2025.74,
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",638.95,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,1400.58,percent of total billed charges,369.26,2025.74,
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1438,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",532.79,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1118.86,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",369.26,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",542.83,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,1206.06,percent of total billed charges,369.26,2025.74,
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,799.19,percent of total billed charges,369.26,2025.74,
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1265.44,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",521.96,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1294.2,percent of total billed charges,369.26,2025.74,
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",532.79,other,369.26,2025.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1742.75,percent of total billed charges,155.95,1770.03,
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",177.44,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",178.78,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1257.47,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1224.14,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",185.05,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1219.23,percent of total billed charges,155.95,1770.03,
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",465.2,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",183.22,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1526.28,percent of total billed charges,155.95,1770.03,
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",192.48,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",155.95,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,1463.72,percent of total billed charges,155.95,1770.03,
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",638.78,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",421.4,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",475.31,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",163.15,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",188.72,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,1598.59,percent of total billed charges,155.95,1770.03,
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,393.39,percent of total billed charges,155.95,1770.03,
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",268.28,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1724.59,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",181.65,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1770.03,percent of total billed charges,155.95,1770.03,
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",183.22,other,155.95,1770.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2360.27,percent of total billed charges,297.79,2891.45,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",371.41,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1750.96,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2501.47,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2686.98,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",373.36,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1809.86,percent of total billed charges,297.79,2891.45,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2514,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",940.23,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",371.41,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,2528.4,percent of total billed charges,297.79,2891.45,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",467.89,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,2835.27,percent of total billed charges,297.79,2891.45,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1337.07,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",569.84,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",779.96,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",297.79,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",382.55,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,2468.82,percent of total billed charges,297.79,2891.45,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,499.52,percent of total billed charges,297.79,2891.45,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",449.17,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2891.45,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2584.66,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",374.99,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,2561.13,percent of total billed charges,297.79,2891.45,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",371.41,other,297.79,2891.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3746.1,percent of total billed charges,749.55,4184.1,
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1194.96,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4184.1,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3900.52,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3659.82,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2549.96,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,3384.49,percent of total billed charges,749.55,4184.1,
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2822.24,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1249.36,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,3459.58,percent of total billed charges,749.55,4184.1,
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4120.84,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",749.55,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2671.52,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,3143.56,percent of total billed charges,749.55,4184.1,
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,2277.43,percent of total billed charges,749.55,4184.1,
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2820.35,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1205.87,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3891.62,percent of total billed charges,749.55,4184.1,
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1844.12,other,749.55,4184.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1533.42,percent of total billed charges,394.88,1834.8,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",398.32,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1637.1,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1470.29,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",398.25,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1219.36,percent of total billed charges,394.88,1834.8,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",981.72,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",394.88,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1479.93,percent of total billed charges,394.88,1834.8,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",493.6,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,1591.65,percent of total billed charges,394.88,1834.8,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1421.56,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1396.24,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",410.27,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1834.8,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",398.75,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1537,percent of total billed charges,394.88,1834.8,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",398.32,other,394.88,1834.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1891.57,percent of total billed charges,521.18,2327.54,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",530.09,other,521.18,2327.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1215.32,other,521.18,2327.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1995.08,other,521.18,2327.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",521.18,other,521.18,2327.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1253.07,percent of total billed charges,521.18,2327.54,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1274.44,other,521.18,2327.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",522,other,521.18,2327.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1789.52,percent of total billed charges,521.18,2327.54,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1862.19,other,521.18,2327.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",527.22,other,521.18,2327.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,2327.54,percent of total billed charges,521.18,2327.54,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",522,other,521.18,2327.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3938.94,percent of total billed charges,983.25,9663.48,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1415.87,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4085.82,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4352.8,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1361.37,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,3318.44,percent of total billed charges,983.25,9663.48,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9663.48,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1371.36,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,3851.59,percent of total billed charges,983.25,9663.48,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1714.2,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,3748.82,percent of total billed charges,983.25,9663.48,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4539.8,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2460.36,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3004.86,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",983.25,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1433.79,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,9097.76,percent of total billed charges,983.25,9663.48,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3767.12,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1361.93,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,4085.82,percent of total billed charges,983.25,9663.48,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1371.36,other,983.25,9663.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2727.88,percent of total billed charges,1585.47,6764.4,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2432.44,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2605.61,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2610.75,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1803.15,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1679.94,percent of total billed charges,1585.47,6764.4,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2075.97,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1712.29,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,5758.2,percent of total billed charges,1585.47,6764.4,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,6764.4,percent of total billed charges,1585.47,6764.4,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4621.07,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3436.36,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4016.72,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2644.46,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,5312.63,percent of total billed charges,1585.47,6764.4,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1585.47,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1721.03,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3124.44,percent of total billed charges,1585.47,6764.4,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1880.91,other,1585.47,6764.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2832.81,other,609.67,45720.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15235.65,other,609.67,45720.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13337.51,other,609.67,45720.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45720.12,other,609.67,45720.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,12299.36,percent of total billed charges,609.67,45720.12,
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8453.62,other,609.67,45720.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5889,other,609.67,45720.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2650.7,other,609.67,45720.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,6309,percent of total billed charges,609.67,45720.12,
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",609.67,other,609.67,45720.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,213.31,percent of total billed charges,52.33,616.8,
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",52.33,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",144,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",140.11,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",102.36,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,156.51,percent of total billed charges,52.33,616.8,
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",205.49,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,526.21,percent of total billed charges,52.33,616.8,
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",188.38,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",53.9,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",474.06,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,298,percent of total billed charges,52.33,616.8,
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,616.8,percent of total billed charges,52.33,616.8,
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",215.88,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",52.85,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,207.9,percent of total billed charges,52.33,616.8,
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",89.3,other,52.33,616.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,780.2,percent of total billed charges,158.43,6830.18,
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",167.75,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",320.4,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",355.75,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",158.43,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,197.92,percent of total billed charges,158.43,6830.18,
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",523,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",159.76,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,6830.18,percent of total billed charges,158.43,6830.18,
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,198,percent of total billed charges,158.43,6830.18,
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",593.85,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,199.18,percent of total billed charges,158.43,6830.18,
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",457.25,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",164.94,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,387.9,percent of total billed charges,158.43,6830.18,
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",164.96,other,158.43,6830.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2511.72,percent of total billed charges,447.76,51986.9,
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5011.62,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2692.82,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2406.67,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",447.76,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1970.45,percent of total billed charges,447.76,51986.9,
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2002.72,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",514.48,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1662.02,percent of total billed charges,447.76,51986.9,
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51986.9,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",465.63,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,1135.39,percent of total billed charges,447.76,51986.9,
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",680.63,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1329,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1414.8,percent of total billed charges,447.76,51986.9,
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",474.81,other,447.76,51986.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3530.82,percent of total billed charges,830.45,3530.82,
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1347.3,percent of total billed charges,830.45,3530.82,
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",830.45,other,830.45,3530.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,223,percent of total billed charges,147.57,889.76,
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",199.58,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",238.4,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",188.14,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",170.79,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",889.76,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",190.08,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",190.08,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",195.78,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",188.14,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,224.1,percent of total billed charges,147.57,889.76,
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",147.57,other,147.57,889.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1579.91,percent of total billed charges,94.21,25073.35,
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",191.79,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1163.25,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6989.36,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",855.86,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.37,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,591.13,percent of total billed charges,94.21,25073.35,
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",572.15,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1873.43,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,720.97,percent of total billed charges,94.21,25073.35,
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1938.1,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,94.21,percent of total billed charges,94.21,25073.35,
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25073.35,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",95.67,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4029,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",138.04,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14684.06,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",300.46,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,940.77,percent of total billed charges,94.21,25073.35,
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",151.53,other,94.21,25073.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2210.74,percent of total billed charges,247.82,10065.9,
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",332.66,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3046.56,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1538.22,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1880.16,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",345.64,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,826.89,percent of total billed charges,247.82,10065.9,
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1014.15,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2061.6,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1053.62,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1590.09,percent of total billed charges,247.82,10065.9,
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1264.4,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,10065.9,percent of total billed charges,247.82,10065.9,
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",910.51,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",247.82,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",600.28,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",255.04,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2098.54,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,8028.41,percent of total billed charges,247.82,10065.9,
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,7681.24,percent of total billed charges,247.82,10065.9,
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1473.92,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1199.48,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",409.93,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1223.45,percent of total billed charges,247.82,10065.9,
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",334.67,other,247.82,10065.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,7741.38,percent of total billed charges,1928.37,27732.84,
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3999.07,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15718.89,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5155.79,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5989.56,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2366.23,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,10271.34,percent of total billed charges,1928.37,27732.84,
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2670.86,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10896.75,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3675.04,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,6310.74,percent of total billed charges,1928.37,27732.84,
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16763.74,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,9091.91,percent of total billed charges,1928.37,27732.84,
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27732.84,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11545.71,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3396.61,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2175.03,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,2032.37,percent of total billed charges,1928.37,27732.84,
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,8019.96,percent of total billed charges,1928.37,27732.84,
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7935.36,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8391.51,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2265.65,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,12193.43,percent of total billed charges,1928.37,27732.84,
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1928.37,other,1928.37,27732.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,365.2,percent of total billed charges,90.17,600,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",150.86,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",90.17,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",540,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",440,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",146.84,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,277.2,percent of total billed charges,90.17,600,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",440,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",440,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",147.75,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,369.6,percent of total billed charges,90.17,600,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",188.58,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,396,percent of total billed charges,90.17,600,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",543.09,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",600,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",92.25,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",152.9,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,341,percent of total billed charges,90.17,600,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,468,percent of total billed charges,90.17,600,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",421.5,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",445.6,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",149.93,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,396,percent of total billed charges,90.17,600,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",148.85,other,90.17,600,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,810.29,percent of total billed charges,208.45,1109.54,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",303.13,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",569,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",601.2,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",668,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",282.78,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,420.84,percent of total billed charges,208.45,1109.54,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1109.54,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",303.13,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1061.43,percent of total billed charges,208.45,1109.54,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",355.66,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,1037.25,percent of total billed charges,208.45,1109.54,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1024.3,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",290.8,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",208.45,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",312.22,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,765.8,percent of total billed charges,208.45,1109.54,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,687.6,percent of total billed charges,208.45,1109.54,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",587.84,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",306.16,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,601.2,percent of total billed charges,208.45,1109.54,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",298.07,other,208.45,1109.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",517.64,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1814.22,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2047.33,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",488.32,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1126.65,percent of total billed charges,488.32,3817.8,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2563.86,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",517.64,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",515.26,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",533.17,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",518,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3817.8,percent of total billed charges,488.32,3817.8,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",517.64,other,488.32,3817.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,3442.01,percent of total billed charges,486.11,4235.4,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1003.25,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",486.11,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3124.77,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3370.84,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",958.78,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2865.95,percent of total billed charges,486.11,4235.4,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3830.79,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1009.75,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,4092,percent of total billed charges,486.11,4235.4,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,3682.8,percent of total billed charges,486.11,4235.4,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3417.44,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4092,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",497.32,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",977.77,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,3171.3,percent of total billed charges,486.11,4235.4,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3777,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1003.53,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,4235.4,percent of total billed charges,486.11,4235.4,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1009.75,other,486.11,4235.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1102.24,percent of total billed charges,99.82,1976.4,
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",949.69,other,99.82,1976.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",117.33,other,99.82,1976.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,719.46,percent of total billed charges,99.82,1976.4,
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",701,other,99.82,1976.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1033.14,other,99.82,1976.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,502.86,percent of total billed charges,99.82,1976.4,
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",441.26,other,99.82,1976.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,1570.4,percent of total billed charges,99.82,1976.4,
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",99.82,other,99.82,1976.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1976.4,percent of total billed charges,99.82,1976.4,
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",233.83,other,99.82,1976.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,157.7,percent of total billed charges,34.5,839.82,
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38.73,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",145.35,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",109.56,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,119.7,percent of total billed charges,34.5,839.82,
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",839.82,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38.73,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,159.6,percent of total billed charges,34.5,839.82,
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,171,percent of total billed charges,34.5,839.82,
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",190,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39.89,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",135.08,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39.12,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,34.5,percent of total billed charges,34.5,839.82,
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38.73,other,34.5,839.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,294.65,percent of total billed charges,73.42,582,
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",429,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",372.03,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",251.64,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",121.54,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,252,percent of total billed charges,73.42,582,
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",283.5,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",270.19,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",122.79,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,327.6,percent of total billed charges,73.42,582,
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",73.42,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",300,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,357.75,percent of total billed charges,73.42,582,
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",210.24,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",123.9,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",118.32,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.47,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,238.54,percent of total billed charges,73.42,582,
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,218.8,percent of total billed charges,73.42,582,
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",582,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",314.7,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",121.54,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,333,percent of total billed charges,73.42,582,
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",122.79,other,73.42,582,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,454.84,percent of total billed charges,53.57,5297.08,
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",123.62,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5297.08,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",319.45,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",371.45,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",121.54,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,296.47,percent of total billed charges,53.57,5297.08,
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",511.67,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",123.08,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,448.82,percent of total billed charges,53.57,5297.08,
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",188.08,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",53.57,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,548.06,percent of total billed charges,53.57,5297.08,
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",434.39,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",116.78,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",293.12,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",171.52,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.47,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,348,percent of total billed charges,53.57,5297.08,
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,739.25,percent of total billed charges,53.57,5297.08,
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",449,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",281.62,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",122.11,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,404.1,percent of total billed charges,53.57,5297.08,
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",123.37,other,53.57,5297.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Minor Procedures,5735,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",235.41,other,235.41,1718.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Minor Procedures,5735,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1718.94,other,235.41,1718.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Minor Procedures,5735,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",383.6,other,235.41,1718.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 5 Minor Procedures,5735,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",384.8,other,235.41,1718.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,100,360,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.37,other,100,360,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",121.54,other,100,360,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",100,other,100,360,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",122.79,other,100,360,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125.12,other,100,360,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.47,other,100,360,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",121.54,other,100,360,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,360,percent of total billed charges,100,360,
Level 1 Electronic Analysis of Devices,5741,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",122.79,other,100,360,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",218.9,other,174.42,231,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",174.42,other,174.42,231,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",231,other,174.42,231,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",230.91,other,174.42,231,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",222.74,other,174.42,231,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Electronic Analysis of Devices,5742,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",224.19,other,174.42,231,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",288.47,other,288.47,416.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",291.32,other,288.47,416.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",404.61,other,288.47,416.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",416.14,other,288.47,416.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,589.3,percent of total billed charges,186.04,1937.6,
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",186.04,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",482.34,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",380.12,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,670.95,percent of total billed charges,186.04,1937.6,
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1065,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",731.94,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,756.3,percent of total billed charges,186.04,1937.6,
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,907.2,percent of total billed charges,186.04,1937.6,
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1937.6,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1391.5,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",502.6,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1192.8,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",485.8,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,958.5,percent of total billed charges,186.04,1937.6,
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",731.94,other,186.04,1937.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2238.29,percent of total billed charges,628.55,4728.5,
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1165.27,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4258.33,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3378.59,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",633.03,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2968.13,percent of total billed charges,628.55,4728.5,
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3922.28,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",814.18,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,3417.02,percent of total billed charges,628.55,4728.5,
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,4277.28,percent of total billed charges,628.55,4728.5,
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4005.41,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4026.7,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",631.44,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2965.92,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",638.81,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,4728.5,percent of total billed charges,628.55,4728.5,
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",628.55,other,628.55,4728.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1636.82,percent of total billed charges,162.15,7083.09,
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",205.99,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1373.61,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1140.64,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",193.37,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,929.88,percent of total billed charges,162.15,7083.09,
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",920.35,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",403.22,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,7083.09,percent of total billed charges,162.15,7083.09,
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",162.15,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",274.26,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",711.2,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",208.05,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,994.98,percent of total billed charges,162.15,7083.09,
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",499.06,other,162.15,7083.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11475.86,other,11475.86,16833.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16833.95,other,11475.86,16833.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Manipulation Therapy,5811,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,61.42,percent of total billed charges,25.38,215.34,
Manipulation Therapy,5811,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56.61,other,25.38,215.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Manipulation Therapy,5811,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50.08,other,25.38,215.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Manipulation Therapy,5811,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28,other,25.38,215.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Manipulation Therapy,5811,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25.38,other,25.38,215.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Manipulation Therapy,5811,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",71.4,other,25.38,215.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Manipulation Therapy,5811,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.37,other,25.38,215.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Manipulation Therapy,5811,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",215.34,other,25.38,215.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",153,other,108.68,249.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",249.78,other,108.68,249.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",151.38,other,108.68,249.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",108.68,other,108.68,249.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",155.38,other,108.68,249.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",152.28,other,108.68,249.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",153,other,108.68,249.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",153,other,108.68,249.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 1 Health and Behavior Services,5821,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",152.94,other,108.68,249.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,266.43,percent of total billed charges,76.77,2763,
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",82.54,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",245.57,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",85.21,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,214.55,percent of total billed charges,76.77,2763,
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",198,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",77.06,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,269.64,percent of total billed charges,76.77,2763,
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,325.8,percent of total billed charges,76.77,2763,
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",277.41,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",231.18,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",79.37,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,174.38,percent of total billed charges,76.77,2763,
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2763,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",318.56,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",76.77,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,288.9,percent of total billed charges,76.77,2763,
Level 2 Health and Behavior Services,5822,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",77.06,other,76.77,2763,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,266.43,percent of total billed charges,141,362,
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",141,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",240.77,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",237.22,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",152.41,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,220.46,percent of total billed charges,141,362,
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",309.42,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",153.98,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,296.48,percent of total billed charges,141,362,
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,270.45,percent of total billed charges,141,362,
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",321,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",323.36,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",362,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",141,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",141,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",304.08,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",141,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,288.9,percent of total billed charges,141,362,
Level 3 Health and Behavior Services,5823,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",141,other,141,362,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Alteplase recombinant,7048,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",364.05,other,298.73,545.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Alteplase recombinant,7048,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",545.45,other,298.73,545.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Alteplase recombinant,7048,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",511.9,other,298.73,545.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Alteplase recombinant,7048,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",411.72,other,298.73,545.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Alteplase recombinant,7048,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",298.73,other,298.73,545.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Alteplase recombinant,7048,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,514.94,percent of total billed charges,298.73,545.45,
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1212.63,percent of total billed charges,242.46,1702.8,
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",718,other,242.46,1702.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1108.87,other,242.46,1702.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",320.6,other,242.46,1702.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,621.18,percent of total billed charges,242.46,1702.8,
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",850.59,other,242.46,1702.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",242.46,other,242.46,1702.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1128.24,percent of total billed charges,242.46,1702.8,
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1115.67,other,242.46,1702.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,996.66,percent of total billed charges,242.46,1702.8,
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",304.64,other,242.46,1702.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,1702.8,percent of total billed charges,242.46,1702.8,
Ultrasound Composite,8004,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",416.07,other,242.46,1702.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,14963.6,percent of total billed charges,231.3,14963.6,
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",654.44,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2791.53,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",233.61,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1786.11,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",231.3,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,2907.45,percent of total billed charges,231.3,14963.6,
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",740.96,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3896.02,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",327.24,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1163.24,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,2751.25,percent of total billed charges,231.3,14963.6,
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12559.78,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",651.64,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3587.8,percent of total billed charges,231.3,14963.6,
CT and CTA without Contrast Composite,8005,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",231.3,other,231.3,14963.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,4928.66,percent of total billed charges,394.85,12399.16,
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",463.14,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",394.85,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4763.56,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4345.64,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",441.59,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,4160.44,percent of total billed charges,394.85,12399.16,
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3500,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1889.43,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",441.09,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,5469.31,percent of total billed charges,394.85,12399.16,
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3808,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4960.1,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,12399.16,percent of total billed charges,394.85,12399.16,
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1587.92,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",931.75,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",464.15,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",764.22,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,4744.88,percent of total billed charges,394.85,12399.16,
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,4414.75,percent of total billed charges,394.85,12399.16,
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",520.1,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4371.11,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",441.09,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,5563.5,percent of total billed charges,394.85,12399.16,
CT and CTA with Contrast Composite,8006,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",441.09,other,394.85,12399.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2176.26,percent of total billed charges,162.45,3181.28,
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",529.82,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",162.45,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",444.66,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3181.28,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",528.42,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2438.43,percent of total billed charges,162.45,3181.28,
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1198.5,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",535.58,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,2960.16,percent of total billed charges,162.45,3181.28,
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1907.35,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",270.6,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",551.65,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1939.13,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",535.12,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,3133.8,percent of total billed charges,162.45,3181.28,
MRI and MRA without Contrast Composite,8007,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",532.7,other,162.45,3181.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,4743.7,percent of total billed charges,284.66,6718.32,
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",902.18,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6447.97,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5357.09,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",844.32,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,3751.3,percent of total billed charges,284.66,6718.32,
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1918.06,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",851,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,6718.32,percent of total billed charges,284.66,6718.32,
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4454.29,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",842.77,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",284.66,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",872.11,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,4359.72,percent of total billed charges,284.66,6718.32,
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,778.6,percent of total billed charges,284.66,6718.32,
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4645.09,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",851.2,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,4950.25,percent of total billed charges,284.66,6718.32,
MRI and MRA with Contrast Composite,8008,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",859.22,other,284.66,6718.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mental Health Services Composite,8010,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",147.02,other,147.02,594,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mental Health Services Composite,8010,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",594,other,147.02,594,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mental Health Services Composite,8010,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",272.5,other,147.02,594,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,10026.56,percent of total billed charges,607.81,13785.66,
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2774.68,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8101.88,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7677.58,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2655.16,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,8963.84,percent of total billed charges,607.81,13785.66,
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2643.51,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8663.5,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2643.51,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,10163.48,percent of total billed charges,607.81,13785.66,
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",607.81,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,13785.66,percent of total billed charges,607.81,13785.66,
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9516.63,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2491.34,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5404.78,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1105.64,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2812.82,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,10171.29,percent of total billed charges,607.81,13785.66,
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10384.15,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13706.56,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2669.95,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,9934.84,percent of total billed charges,607.81,13785.66,
Comprehensive Observation Services,8011,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2668.56,other,607.81,13785.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inj inotuzumab ozogam 0.1 mg,9028,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",116652.87,other,116652.87,116652.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Thyrotropin injection,9108,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4109.49,other,2066.74,4906.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Thyrotropin injection,9108,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2988.18,percent of total billed charges,2066.74,4906.7,
Thyrotropin injection,9108,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4906.7,other,2066.74,4906.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Thyrotropin injection,9108,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2066.74,other,2066.74,4906.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Thyrotropin injection,9108,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,4891.7,percent of total billed charges,2066.74,4906.7,
Natalizumab injection,9126,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5.41,other,5.41,5.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Rabies ig, im/sc",9133,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7770.29,other,5257.98,7770.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Rabies ig, im/sc",9133,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,6643.07,percent of total billed charges,5257.98,7770.29,
"Rabies ig, im/sc",9133,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6116.4,other,5257.98,7770.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Rabies ig, im/sc",9133,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,5257.98,percent of total billed charges,5257.98,7770.29,
"Rabies ig, im/sc",9133,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,7703.69,percent of total billed charges,5257.98,7770.29,
"Rabies ig, im/sc",9133,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6005.53,other,5257.98,7770.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Rabies ig, im/sc",9133,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6654.3,other,5257.98,7770.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Rabies vaccine, im",9139,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,923.46,percent of total billed charges,470.47,923.46,
"Rabies vaccine, im",9139,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",743.85,other,470.47,923.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Rabies vaccine, im",9139,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,546.7,percent of total billed charges,470.47,923.46,
"Rabies vaccine, im",9139,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",617.65,other,470.47,923.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Rabies vaccine, im",9139,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,626.33,percent of total billed charges,470.47,923.46,
"Rabies vaccine, im",9139,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,564.93,percent of total billed charges,470.47,923.46,
"Rabies vaccine, im",9139,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",527.27,other,470.47,923.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Rabies vaccine, im",9139,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,492.03,percent of total billed charges,470.47,923.46,
"Rabies vaccine, im",9139,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",470.47,other,470.47,923.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inj acetaminophen -fresenius,9143,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,55113.7,percent of total billed charges,55113.7,55113.7,
"Inj mosunetuzumab-axgb, 1 mg",9150,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21323.26,other,21323.26,21323.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, fulphila",9173,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1538.51,other,1402.29,4441.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, fulphila",9173,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4092.49,other,1402.29,4441.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, fulphila",9173,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3219.42,other,1402.29,4441.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, fulphila",9173,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1528.76,other,1402.29,4441.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, fulphila",9173,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4441.9,other,1402.29,4441.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, fulphila",9173,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1402.29,other,1402.29,4441.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, fulphila",9173,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2097.56,other,1402.29,4441.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, fulphila",9173,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1648.24,other,1402.29,4441.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, burosumab-twza 1m",9187,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34793.81,other,34793.81,34793.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nivestym,9193,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",136.8,other,136.8,136.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, udenyca 0.5 mg",9195,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7370.36,other,1533.27,7979.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, udenyca 0.5 mg",9195,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1548.6,other,1533.27,7979.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, udenyca 0.5 mg",9195,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7979.35,other,1533.27,7979.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, udenyca 0.5 mg",9195,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,6535.09,percent of total billed charges,1533.27,7979.35,
"Injection, udenyca 0.5 mg",9195,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1765.52,other,1533.27,7979.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, udenyca 0.5 mg",9195,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1582.58,other,1533.27,7979.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, udenyca 0.5 mg",9195,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,7181.42,percent of total billed charges,1533.27,7979.35,
"Injection, udenyca 0.5 mg",9195,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1533.27,other,1533.27,7979.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj tisotu vedotin-tftv, 1mg",9204,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,49977.52,percent of total billed charges,49977.52,49977.52,
Leuprolide acetate suspnsion,9217,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,16624.27,percent of total billed charges,377.7,16624.27,
Leuprolide acetate suspnsion,9217,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",377.7,other,377.7,16624.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Leuprolide acetate suspnsion,9217,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",652.14,other,377.7,16624.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Leuprolide acetate suspnsion,9217,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1689.05,other,377.7,16624.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Leuprolide acetate suspnsion,9217,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2352.71,other,377.7,16624.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Leuprolide acetate suspnsion,9217,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,1218.42,percent of total billed charges,377.7,16624.27,
Leuprolide acetate suspnsion,9217,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1334.07,other,377.7,16624.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Leuprolide acetate suspnsion,9217,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",616.5,other,377.7,16624.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Leuprolide acetate suspnsion,9217,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",631.08,other,377.7,16624.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Romiplostim injection,9245,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8083.6,other,785.95,14864.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Romiplostim injection,9245,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1216.92,other,785.95,14864.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Romiplostim injection,9245,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3220.7,other,785.95,14864.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Romiplostim injection,9245,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",785.95,other,785.95,14864.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Romiplostim injection,9245,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14864.29,other,785.95,14864.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Romiplostim injection,9245,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3809.46,other,785.95,14864.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inj epcoritamab-bysp 0.16 mg,9250,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1472.6,other,1472.6,1472.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj, denosumab",9272,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2803.8,other,1115.02,2803.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj, denosumab",9272,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1115.02,other,1115.02,2803.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj, denosumab",9272,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1520.07,other,1115.02,2803.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj, denosumab",9272,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1511.88,other,1115.02,2803.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cabazitaxel injection,9276,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16002.49,other,16002.49,16002.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, pegloticase",9281,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26834.38,other,26834.38,26834.38,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ipilimumab injection,9284,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",65429.03,other,26357.12,69256.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ipilimumab injection,9284,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",57848.44,other,26357.12,69256.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ipilimumab injection,9284,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",69256.31,other,26357.12,69256.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ipilimumab injection,9284,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44562.62,other,26357.12,69256.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ipilimumab injection,9284,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,26357.12,percent of total billed charges,26357.12,69256.31,
Ipilimumab injection,9284,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45635.04,other,26357.12,69256.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3397.13,other,3397.13,14749.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,14749.69,percent of total billed charges,3397.13,14749.69,
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14419.37,other,3397.13,14749.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3581.26,other,3397.13,14749.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Omalizumab injection,9300,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8268.52,other,1821.44,8268.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Omalizumab injection,9300,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5531.92,other,1821.44,8268.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Omalizumab injection,9300,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1821.44,other,1821.44,8268.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj., ravulizumab-cwvz 10 mg",9312,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",143697.13,other,21798.56,143697.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj., ravulizumab-cwvz 10 mg",9312,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21798.56,other,21798.56,143697.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj., ravulizumab-cwvz 10 mg",9312,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",73610.34,other,21798.56,143697.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj., ravulizumab-cwvz 10 mg",9312,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",73382.85,other,21798.56,143697.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj., ravulizumab-cwvz 10 mg",9312,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",74116.68,other,21798.56,143697.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inj luspatercept-aamt 0.25mg,9347,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34453.71,other,34453.71,43143.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inj luspatercept-aamt 0.25mg,9347,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,43143.44,percent of total billed charges,34453.71,43143.44,
Inj. teprotumumab-trbw 10 mg,9355,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",48905.6,other,48905.6,83480,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inj. teprotumumab-trbw 10 mg,9355,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",83480,other,48905.6,83480,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inj. teprotumumab-trbw 10 mg,9355,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",65138.22,other,48905.6,83480,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj, metronidazole, 10 mg",9369,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14015.93,other,14015.93,22682.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj, metronidazole, 10 mg",9369,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,22682.64,percent of total billed charges,14015.93,22682.64,
Mitomycin instillation,9374,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",58759.02,other,58759.02,58759.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Daratumumab, hyaluronidase",9378,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8944.35,other,8944.35,8944.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj. lurbinectedin, 0.1 mg",9389,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15657.06,other,15657.06,45487.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj. lurbinectedin, 0.1 mg",9389,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45487.69,other,15657.06,45487.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj. lurbinectedin, 0.1 mg",9389,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16220.6,other,15657.06,45487.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj. lurbinectedin, 0.1 mg",9389,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16288.91,other,15657.06,45487.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Pertuzu, trastuzu, 10 mg",9390,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16259.42,other,16259.42,16259.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Afamelanotide implant, 1 mg",9396,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,96439.39,percent of total billed charges,96439.39,96439.39,
"Inj, labetalol hcl, 5mg",9400,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9591.8,other,9591.8,9591.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inj pegfilgrast ex bio 0.5mg,9436,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,5201.4,percent of total billed charges,1097.07,5201.4,
Inj pegfilgrast ex bio 0.5mg,9436,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1097.07,other,1097.07,5201.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inj ferric carboxymaltos 1mg,9441,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2293.82,other,2293.82,2293.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, nivolumab",9453,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15052.79,other,15052.79,15052.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Injection, siltuximab",9455,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,20331.46,percent of total billed charges,20331.46,32344.17,
"Injection, siltuximab",9455,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32344.17,other,20331.46,32344.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Inj., benralizumab, 1 mg",9466,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5246.8,other,5246.8,5246.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Injection trabectedin 0.1mg,9480,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9006.89,other,9006.89,9006.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2778.29,other,882.47,6613.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6613.79,other,882.47,6613.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",882.47,other,882.47,6613.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6124.89,other,882.47,6613.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1199.56,other,882.47,6613.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Platelet pheres leukoreduced,9501,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1765.58,other,882.47,6613.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4746.24,other,657.81,8607.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5453.96,other,657.81,8607.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4562.62,other,657.81,8607.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",657.81,other,657.81,8607.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8607.34,other,657.81,8607.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1548.09,other,657.81,8607.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2053.36,other,657.81,8607.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,234.06,percent of total billed charges,39.43,325.78,
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",206.9,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39.43,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42.53,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",121.54,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,60.48,percent of total billed charges,39.43,325.78,
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",228.72,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,74.34,percent of total billed charges,39.43,325.78,
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,285.3,percent of total billed charges,39.43,325.78,
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",110.18,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,245.69,percent of total billed charges,39.43,325.78,
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,325.78,percent of total billed charges,39.43,325.78,
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",126.34,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",228.68,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",122.5,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,285.3,percent of total billed charges,39.43,325.78,
Non-OPPS Clinic Services,N700,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",127.67,other,39.43,325.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,136.95,percent of total billed charges,10.37,220.54,
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45.55,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",52.73,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",220.54,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",170,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40.08,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,107.1,percent of total billed charges,10.37,220.54,
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",66,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",75.82,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41.27,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,130.2,percent of total billed charges,10.37,220.54,
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",90.71,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10.37,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,137.7,percent of total billed charges,10.37,220.54,
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",120,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",55.7,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",117.6,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21.46,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35.83,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,106.58,percent of total billed charges,10.37,220.54,
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,96,percent of total billed charges,10.37,220.54,
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",160,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",95.54,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41.09,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,153,percent of total billed charges,10.37,220.54,
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42.23,other,10.37,220.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,732.89,percent of total billed charges,92.34,5186.72,
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",230.46,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",134.37,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",675.9,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",649.56,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",210.49,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,578.34,percent of total billed charges,92.34,5186.72,
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5186.72,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",469.26,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",202.87,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,786.24,percent of total billed charges,92.34,5186.72,
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",172.58,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",177.19,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,883.48,percent of total billed charges,92.34,5186.72,
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",749.44,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",450.52,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",489.39,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",92.34,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",216.38,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,705.68,percent of total billed charges,92.34,5186.72,
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,399.16,percent of total billed charges,92.34,5186.72,
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1190,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",676.72,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",212.94,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,851.4,percent of total billed charges,92.34,5186.72,
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",232.97,other,92.34,5186.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,260.75,percent of total billed charges,56.56,368,
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",109.62,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",266.23,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",237.36,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",368,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",103.35,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,185.9,percent of total billed charges,56.56,368,
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",236.51,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",105.46,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,321.05,percent of total billed charges,56.56,368,
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",148.46,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56.56,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,331.2,percent of total billed charges,56.56,368,
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",159.85,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",243.38,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",221.47,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",108.62,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",108.49,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,285.2,percent of total billed charges,56.56,368,
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,233.1,percent of total billed charges,56.56,368,
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",360.5,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",323.84,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",104.39,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,161.42,percent of total billed charges,56.56,368,
Mammography Services,N804,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",105.33,other,56.56,368,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,125,percent of total billed charges,29.96,125,
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,29.96,125,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29.96,other,29.96,125,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",55.36,other,29.96,125,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29.96,other,29.96,125,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30.86,other,29.96,125,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30.26,other,29.96,125,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29.96,other,29.96,125,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,1697.18,percent of total billed charges,37.11,4597.8,
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2324.26,other,37.11,4597.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,1010.28,percent of total billed charges,37.11,4597.8,
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",91.87,other,37.11,4597.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,1667.62,percent of total billed charges,37.11,4597.8,
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",131.23,other,37.11,4597.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,2748.48,percent of total billed charges,37.11,4597.8,
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,3565.95,percent of total billed charges,37.11,4597.8,
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4597.8,other,37.11,4597.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1512,other,37.11,4597.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37.11,other,37.11,4597.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Observation, Other",N811,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,2540.24,percent of total billed charges,37.11,4597.8,
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1295.73,other,125,1295.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",198.18,other,125,1295.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1146.94,other,125,1295.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,1105.9,percent of total billed charges,125,1295.73,
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,125,1295.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125,other,125,1295.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,83,,2841.94,percent of total billed charges,195.75,9332.8,
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",371.41,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3072.65,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2310.49,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",372,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera All Commercial Plans,,60.9,,2063.44,percent of total billed charges,195.75,9332.8,
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3455.65,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1522.79,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",374.31,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,81.9,,2619.96,percent of total billed charges,195.75,9332.8,
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,First Choice,All Commercial Plans,,85.3,,4525.62,percent of total billed charges,195.75,9332.8,
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1347.51,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",374.31,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",195.75,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,2168.1,percent of total billed charges,195.75,9332.8,
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,9332.8,percent of total billed charges,195.75,9332.8,
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3260.45,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2794.78,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",375.9,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,All Commercial Plans,,90,,2934.27,percent of total billed charges,195.75,9332.8,
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",371.41,other,195.75,9332.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1399.76,other,1399.76,1399.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Not Billable to FI,N907,APC,,,,,,,facility,outpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",214,other,214,214,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
HYDRALAZINE 20 MG/ML SOLN,10121,CDM,636,RC,J0360,HCPCS,517090125,NDC,facility,both,20,ME,,50.33,37.75,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML SOLN,10121,CDM,636,RC,J0360,HCPCS,72572026501,NDC,facility,both,20,ME,,42.62,31.97,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML SOLN,10121,CDM,636,RC,J0360,HCPCS,63323061401,NDC,facility,both,20,ME,,39.34,29.51,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML SOLN,10121,CDM,636,RC,J0360,HCPCS,641623125,NDC,facility,both,20,ME,,65.3,48.98,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 10 MG TABS,10122,CDM,250,RC,51079007420,NDC,,,facility,both,1.5,UN,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 10 MG TABS,10122,CDM,250,RC,51079007420,NDC,,,facility,both,2.5,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 10 MG TABS,10122,CDM,250,RC,51079007420,NDC,,,facility,both,1,UN,,7.27,5.45,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 10 MG TABS,10122,CDM,250,RC,23155000110,NDC,,,facility,both,2,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 10 MG TABS,10122,CDM,250,RC,51079007420,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 10 MG TABS,10122,CDM,250,RC,23155000110,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 10 MG TABS,10122,CDM,250,RC,23155000110,NDC,,,facility,both,2.5,UN,,2.22,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,51079007520,NDC,,,facility,both,1,UN,,7.33,5.5,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,63739032710,NDC,,,facility,both,2,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,23155000201,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,50111032701,NDC,,,facility,both,2,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,50111032701,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,63739032710,NDC,,,facility,both,4,UN,,2.16,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,23155000201,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,51079007520,NDC,,,facility,both,0.5,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,50111032701,NDC,,,facility,both,4,UN,,1.78,1.33,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,63739032710,NDC,,,facility,both,1,UN,,6.71,5.03,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,51079007520,NDC,,,facility,both,4,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,63739032710,NDC,,,facility,both,3,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,63739032710,NDC,,,facility,both,2.48,UN,,2.62,1.96,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 25 MG TABS,10124,CDM,250,RC,51079007520,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,16729018301,NDC,,,facility,both,0.25,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,60687059301,NDC,,,facility,both,1.5,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,16729018301,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,60687059301,NDC,,,facility,both,2,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,60687059301,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,60687059301,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,16729018301,NDC,,,facility,both,0.5,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,16729018301,NDC,,,facility,both,1.5,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,60687059301,NDC,,,facility,both,0.25,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 25 MG TABS,10190,CDM,250,RC,16729018301,NDC,,,facility,both,2,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 50 MG TABS,10191,CDM,250,RC,172208960,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 50 MG TABS,10191,CDM,250,RC,172208960,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
Noncdm Charge Record Medical Supplies,1019248_A4649_272,CDM,272,RC,A4649,HCPCS,,,facility,both,,,,1335.76,1001.82,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
HYDROCORTISONE 2.5 % CREA 20 G TUBE,10210,CDM,250,RC,MHS1GM,HCPCS,472033720,NDC,facility,both,1,GM,,2.05,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 2.5 % CREA 28 G TUBE,10210,CDM,250,RC,MHS1GM,HCPCS,45802000403,NDC,facility,both,1,GM,,1.56,1.17,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 2.5 % CREA 30 G TUBE,10210,CDM,250,RC,MHS1GM,HCPCS,472033730,NDC,facility,both,1,GM,,1.62,1.21,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 2.5 % LOTN 59 ML BOTTLE,10214,CDM,250,RC,45802093716,NDC,,,facility,both,59,ML,,61.35,46.01,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 2.5 % OINT 28.35 G TUBE,10217,CDM,250,RC,MHS1GM,HCPCS,168014630,NDC,facility,both,1,GM,,1.45,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,64380097106,NDC,,,facility,both,1.5,UN,,5.22,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,904718861,NDC,,,facility,both,2,UN,,6.82,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,904718861,NDC,,,facility,both,1,UN,,10.42,7.81,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,59762007401,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,60687058201,NDC,,,facility,both,3,UN,,5.87,4.4,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,60687058201,NDC,,,facility,both,1.5,UN,,6.48,4.86,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,59762007401,NDC,,,facility,both,0.5,UN,,6.66,5,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,60687058201,NDC,,,facility,both,0.5,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,59762007401,NDC,,,facility,both,1.5,UN,,3.96,2.97,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,904718861,NDC,,,facility,both,1.5,UN,,6.12,4.59,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,60687058201,NDC,,,facility,both,4,UN,,5.12,3.84,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,64380097106,NDC,,,facility,both,0.5,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,64380097106,NDC,,,facility,both,2,UN,,5.68,4.26,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,60687058201,NDC,,,facility,both,2.5,UN,,5.37,4.02,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,60687058201,NDC,,,facility,both,0.25,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,59762007401,NDC,,,facility,both,2.5,UN,,3.07,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,59762007401,NDC,,,facility,both,0.25,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,904718861,NDC,,,facility,both,2.5,UN,,5,3.75,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,904718861,NDC,,,facility,both,0.5,UN,,9.2,6.9,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,64380097106,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,60687058201,NDC,,,facility,both,1,UN,,11.25,8.44,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,64380097106,NDC,,,facility,both,2.5,UN,,4.07,3.05,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,59762007401,NDC,,,facility,both,1,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG TABS,10220,CDM,250,RC,60687058201,NDC,,,facility,both,2,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG TABS,10221,CDM,250,RC,59762007501,NDC,,,facility,both,0.25,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG TABS,10221,CDM,250,RC,59762007501,NDC,,,facility,both,1,UN,,8.29,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG TABS,10221,CDM,250,RC,59762007501,NDC,,,facility,both,2,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG TABS,10221,CDM,250,RC,59762007501,NDC,,,facility,both,0.75,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG TABS,10221,CDM,250,RC,59762007501,NDC,,,facility,both,3,UN,,3.62,2.71,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG TABS,10221,CDM,250,RC,59762007501,NDC,,,facility,both,0.5,UN,,7.57,5.68,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 25 MG SUPP,10231,CDM,250,RC,574709012,NDC,,,facility,both,1,UN,,41.15,30.86,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 1 MG/ML SOLN,10270,CDM,636,RC,J1170,HCPCS,76045000906,NDC,facility,both,0.1,ME,,39.14,29.36,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 1 MG/ML SOLN,10270,CDM,636,RC,J1170,HCPCS,76045000911,NDC,facility,both,0.1,ME,,38.08,28.56,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 1 MG/ML SOLN,10270,CDM,636,RC,J1170,HCPCS,409128331,NDC,facility,both,0.1,ME,,37.35,28.02,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 1 MG/ML SOLN,10270,CDM,636,RC,J1170,HCPCS,63323085225,NDC,facility,both,0.1,ME,,44.23,33.17,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG/ML SOLN,10271,CDM,636,RC,J1170,HCPCS,409131230,NDC,facility,both,0.1,ME,,35.84,26.88,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG/ML SOLN,10271,CDM,636,RC,J1170,HCPCS,409336501,NDC,facility,both,0.1,ME,,37.25,27.94,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG/ML SOLN 20 ML VIAL,10271,CDM,636,RC,J1170,HCPCS,641234141,NDC,facility,both,0.1,ME,,7.66,5.75,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG/ML SOLN 20 ML VIAL,10271,CDM,636,RC,J1170,HCPCS,641234139,NDC,facility,both,0.1,ME,,7.94,5.95,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030125,NDC,,,facility,both,2,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030101,NDC,,,facility,both,0.5,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,60687057901,NDC,,,facility,both,0.5,UN,,5.4,4.05,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,406324301,NDC,,,facility,both,4,UN,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,60687057901,NDC,,,facility,both,4,UN,,1.72,1.29,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,406324301,NDC,,,facility,both,2,UN,,2.74,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030101,NDC,,,facility,both,1,UN,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030125,NDC,,,facility,both,1.5,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,60687057901,NDC,,,facility,both,2,UN,,3.02,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,60687057901,NDC,,,facility,both,1.5,UN,,2.55,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,60687057901,NDC,,,facility,both,1,UN,,5.47,4.1,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,60687057901,NDC,,,facility,both,3,UN,,1.96,1.47,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030101,NDC,,,facility,both,2,UN,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030125,NDC,,,facility,both,1,UN,,5.53,4.15,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030125,NDC,,,facility,both,4,UN,,1.64,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030125,NDC,,,facility,both,2.5,UN,,2.02,1.51,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030125,NDC,,,facility,both,3,UN,,2.07,1.55,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030125,NDC,,,facility,both,0.5,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,42858030101,NDC,,,facility,both,3,UN,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,406324301,NDC,,,facility,both,3,UN,,1.82,1.36,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,406324301,NDC,,,facility,both,0.5,UN,,4.94,3.7,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,60687057901,NDC,,,facility,both,2.5,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 2 MG TABS,10275,CDM,250,RC,406324301,NDC,,,facility,both,1,UN,,5.31,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,406324401,NDC,,,facility,both,2,UN,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,42858030225,NDC,,,facility,both,2,UN,,2.98,2.23,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,42858030225,NDC,,,facility,both,0.5,UN,,5.4,4.05,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,42858030225,NDC,,,facility,both,1,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,60687059001,NDC,,,facility,both,0.75,UN,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,60687059001,NDC,,,facility,both,1,UN,,5.22,3.91,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,60687059001,NDC,,,facility,both,0.5,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,406324401,NDC,,,facility,both,0.75,UN,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,60687059001,NDC,,,facility,both,2,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,42858030225,NDC,,,facility,both,2.5,UN,,2.05,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,406324401,NDC,,,facility,both,0.5,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,406324401,NDC,,,facility,both,1.25,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 4 MG TABS,10277,CDM,250,RC,406324401,NDC,,,facility,both,1,UN,,5.09,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,55111053401,NDC,,,facility,both,4,UN,,3.41,2.56,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,904718245,NDC,,,facility,both,3,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,50268026013,NDC,,,facility,both,0.5,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,904718245,NDC,,,facility,both,1,UN,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,55111053401,NDC,,,facility,both,1,UN,,8.04,6.03,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,51079076701,NDC,,,facility,both,1,UN,,9.45,7.09,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,16714048501,NDC,,,facility,both,2,UN,,4.61,3.46,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,51079076701,NDC,,,facility,both,4,UN,,4.89,3.67,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,50268026013,NDC,,,facility,both,2.5,UN,,4.02,3.01,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,51079076701,NDC,,,facility,both,3,UN,,5.62,4.21,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,904718245,NDC,,,facility,both,1.5,UN,,6.88,5.16,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,55111053401,NDC,,,facility,both,2,UN,,4.93,3.69,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,50268026013,NDC,,,facility,both,4,UN,,3.62,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,55111053401,NDC,,,facility,both,3,UN,,4.08,3.06,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,50268026013,NDC,,,facility,both,1,UN,,8.59,6.44,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,51079076701,NDC,,,facility,both,2,UN,,6.83,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,50268026013,NDC,,,facility,both,3,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,16714048501,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,904718245,NDC,,,facility,both,4,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,50268026013,NDC,,,facility,both,2,UN,,5.52,4.14,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 500 MG TB24,103261,CDM,250,RC,904718245,NDC,,,facility,both,2,UN,,7.82,5.87,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 0.05 MG/ML SOLN,103265,CDM,636,RC,J3489,HCPCS,67457061910,NDC,facility,both,1,ME,,136.51,102.38,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 0.05 MG/ML SOLN,103265,CDM,636,RC,J3489,HCPCS,25021083082,NDC,facility,both,1,ME,,29.33,22,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 0.05 MG/ML SOLN,103265,CDM,636,RC,J3489,HCPCS,78043561,NDC,facility,both,1,ME,,495.99,371.99,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 0.05 MG/ML SOLN,103265,CDM,636,RC,J3489,HCPCS,63323096600,NDC,facility,both,1,ME,,33.88,25.41,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 0.05 MG/ML SOLN,103265,CDM,636,RC,J3489,HCPCS,55111068852,NDC,facility,both,1,ME,,35.89,26.92,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML SOLN,10334,CDM,636,RC,J3410,HCPCS,517560125,NDC,facility,both,25,ME,,62.54,46.9,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5ML SYRP,10335,CDM,250,RC,MHS5ML,HCPCS,60432015016,NDC,facility,both,5,ML,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,42806015910,NDC,,,facility,both,2.5,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,63739048310,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,63739048310,NDC,,,facility,both,2,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,63739048310,NDC,,,facility,both,2.5,UN,,2.73,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,68084025301,NDC,,,facility,both,1,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,16714008110,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,42806015910,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,63739048310,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,16714008110,NDC,,,facility,both,2.5,UN,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 10 MG TABS,10336,CDM,250,RC,16714008110,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,63739048610,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,904661761,NDC,,,facility,both,4,UN,,2.46,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,63739048610,NDC,,,facility,both,0.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,63739048610,NDC,,,facility,both,4,UN,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,904661761,NDC,,,facility,both,0.5,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,63739048610,NDC,,,facility,both,1,UN,,7.28,5.46,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,16714008210,NDC,,,facility,both,2,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,63739048610,NDC,,,facility,both,1.5,UN,,3.98,2.98,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,904661761,NDC,,,facility,both,1,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,904661761,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,63739048610,NDC,,,facility,both,3,UN,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE HCL 25 MG TABS,10338,CDM,250,RC,904661761,NDC,,,facility,both,1.5,UN,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,185067401,NDC,,,facility,both,1,UN,,6.48,4.86,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,51079007720,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,904706561,NDC,,,facility,both,4,UN,,2.94,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,51079007720,NDC,,,facility,both,4,UN,,1.71,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,51079007720,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,60687069611,NDC,,,facility,both,4,UN,,2.62,1.97,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,904706561,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,60687069611,NDC,,,facility,both,1,UN,,8.04,6.03,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,185067401,NDC,,,facility,both,2,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,185067401,NDC,,,facility,both,4,UN,,1.9,1.43,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,904706561,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,60687069611,NDC,,,facility,both,3,UN,,3.27,2.45,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 25 MG CAPS,10342,CDM,250,RC,60687069611,NDC,,,facility,both,2,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 50 MG CAPS,10343,CDM,250,RC,50268039950,NDC,,,facility,both,2,UN,,4.82,3.62,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 50 MG CAPS,10343,CDM,250,RC,50268039950,NDC,,,facility,both,3,UN,,3.57,2.67,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 50 MG CAPS,10343,CDM,250,RC,50268039950,NDC,,,facility,both,1,UN,,8.63,6.48,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 50 MG CAPS,10343,CDM,250,RC,185067601,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE 50 MG CAPS,10343,CDM,250,RC,185067601,NDC,,,facility,both,2,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
ECULIZUMAB 10 MG/ML SOLN 30 ML VIAL,103499,CDM,636,RC,J1300,HCPCS,25682000101,NDC,facility,both,10,ME,,536.16,402.12,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT AERO 10.2 G INHALER,103945,CDM,250,RC,186037220,NDC,,,facility,both,10.2,GR,,483.4,362.55,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT AERO 6.9 G INHALER,103945,CDM,250,RC,186037228,NDC,,,facility,both,6.9,GR,,272.75,204.56,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT AERO 6 G INHALER,103946,CDM,250,RC,MHS1GM,HCPCS,186037028,NDC,facility,both,1,GM,,46.68,35.01,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 30 MG CAPS,103950,CDM,250,RC,42858016301,NDC,,,facility,both,1,UN,,21.04,15.78,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 30 MG CAPS,103950,CDM,250,RC,59417010310,NDC,,,facility,both,1,UN,,27.65,20.74,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 30 MG CAPS,103950,CDM,250,RC,65162002409,NDC,,,facility,both,1.3333,UN,,5.38,4.03,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 30 MG CAPS,103950,CDM,250,RC,59417010310,NDC,,,facility,both,2,UN,,26.27,19.7,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 30 MG CAPS,103950,CDM,250,RC,65162002409,NDC,,,facility,both,1,UN,,8.08,6.06,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 50 MG CAPS,103951,CDM,250,RC,59417010510,NDC,,,facility,both,1,UN,,29.01,21.76,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 50 MG CAPS,103951,CDM,250,RC,59417010510,NDC,,,facility,both,0.4,UN,,15.65,11.74,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 50 MG CAPS 100 EACH BOTTLE,103951,CDM,250,RC,59417010510,NDC,,,facility,both,1,UN,,30.42,22.81,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSE 40 % GEL,103959,CDM,250,RC,MHS1GM,HCPCS,574006915,NDC,facility,both,1,GM,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSE 40 % GEL 37.5 G PACKAGE,103959,CDM,250,RC,MHS1GM,HCPCS,574007030,NDC,facility,both,1,GM,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL 100 MG/10ML SOLN,104212,CDM,636,RC,J1805,HCPCS,10019012039,NDC,facility,both,10,ME,,8.13,6.1,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL 100 MG/10ML SOLN,104212,CDM,250,RC,J1805,HCPCS,55150019410,NDC,facility,both,10,ME,,4.06,3.05,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL 100 MG/10ML SOLN,104212,CDM,250,RC,55150019410,NDC,,,facility,both,10,ME,,40.65,30.49,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL 100 MG/10ML SOLN,104212,CDM,636,RC,J1805,HCPCS,55150019410,NDC,facility,both,10,ME,,4.04,3.03,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TB24,104526,CDM,250,RC,50742063760,NDC,,,facility,both,2,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TB24,104526,CDM,250,RC,904680361,NDC,,,facility,both,1,UN,,6.83,5.13,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TB24,104526,CDM,250,RC,904680361,NDC,,,facility,both,2,UN,,5.99,4.49,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TB24,104526,CDM,250,RC,50742063760,NDC,,,facility,both,1,UN,,7.24,5.43,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TB24,104527,CDM,250,RC,50742063860,NDC,,,facility,both,2,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TB24,104527,CDM,250,RC,16729009612,NDC,,,facility,both,1,UN,,7.25,5.43,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TB24,104527,CDM,250,RC,904680461,NDC,,,facility,both,2,UN,,6.18,4.63,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TB24,104527,CDM,250,RC,904680461,NDC,,,facility,both,0.166666667,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TB24,104527,CDM,250,RC,50742063860,NDC,,,facility,both,1.6667,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TB24,104527,CDM,250,RC,904680461,NDC,,,facility,both,1,UN,,7.52,5.64,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TB24,104527,CDM,250,RC,50742063860,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TB24,104527,CDM,250,RC,904680461,NDC,,,facility,both,0.3333,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TB24,104527,CDM,250,RC,16729009612,NDC,,,facility,both,2,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
ROTIGOTINE 4 MG/24HR PT24,104533,CDM,250,RC,50474080403,NDC,,,facility,both,1,UN,,63.05,47.29,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE (HYPERTONIC) 7 % NEBU,104566,CDM,250,RC,MHS1ML,HCPCS,487900730,NDC,facility,both,1,ML,,3.26,2.45,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE (HYPERTONIC) 7 % NEBU,104566,CDM,250,RC,MHS1ML,HCPCS,50190014123,NDC,facility,both,1,ML,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE (HYPERTONIC) 7 % NEBU,104566,CDM,250,RC,MHS1ML,HCPCS,83490030760,NDC,facility,both,1,ML,,3.09,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE INHALANT 7 % NEBU,104566,CDM,250,RC,MHS1ML,HCPCS,50190014123,NDC,facility,both,1,ML,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE INHALANT 7 % NEBU,104566,CDM,250,RC,MHS1ML,HCPCS,487900730,NDC,facility,both,1,ML,,3.26,2.45,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,70700018922,NDC,facility,both,500,ME,,15.46,11.6,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,25021021598,NDC,facility,both,500,ME,,5.98,4.48,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,25021021599,NDC,facility,both,500,ME,,7.98,5.99,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,62332075150,NDC,facility,both,500,ME,,17.35,13.01,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,16729027638,NDC,facility,both,500,ME,,19.53,14.65,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,both,500,ME,,5.29,3.97,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,70700018623,NDC,facility,both,500,ME,,23.65,17.74,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,both,500,ME,,6.01,4.51,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,70700018822,NDC,facility,both,500,ME,,19.37,14.53,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,both,500,ME,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,63323011751,NDC,facility,both,500,ME,,5.37,4.03,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,16729027667,NDC,facility,both,500,ME,,36.64,27.48,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN,104636,CDM,636,RC,J9190,HCPCS,62332077931,NDC,facility,both,500,ME,,21.12,15.84,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN,104733,CDM,636,RC,J0736,HCPCS,9077526,NDC,facility,both,300,ME,,19.85,14.89,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN 4 ML VIAL,104733,CDM,636,RC,J0736,HCPCS,9077526,NDC,facility,both,300,ME,,26.1,19.58,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN 4 ML VIAL,104733,CDM,250,RC,J0736,HCPCS,9077526,NDC,facility,both,300,ME,,16.44,12.33,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN,104734,CDM,636,RC,J0736,HCPCS,9090218,NDC,facility,both,300,ME,,14.83,11.12,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN,104734,CDM,250,RC,MHS1ML,HCPCS,9090218,NDC,facility,both,300,ME,,7.42,5.56,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN 6 ML VIAL,104734,CDM,250,RC,MHS1ML,HCPCS,25021011506,NDC,facility,both,300,ME,,7.47,5.6,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN 6 ML VIAL,104734,CDM,636,RC,J0736,HCPCS,25021011506,NDC,facility,both,300,ME,,14.93,11.2,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN 6 ML VIAL,104734,CDM,636,RC,J0736,HCPCS,9090218,NDC,facility,both,300,ME,,14.83,11.12,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN 6 ML VIAL,104734,CDM,250,RC,MHS1ML,HCPCS,9090218,NDC,facility,both,300,ME,,7.42,5.56,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML SOLN 2 ML VIAL,104735,CDM,636,RC,J0736,HCPCS,9087026,NDC,facility,both,300,ME,,24.42,18.32,,,,,,,,,,Gross Charge Type: Pharmacy
AMBRISENTAN 5 MG TABS,104739,CDM,250,RC,47335023683,NDC,,,facility,both,2,UN,,78.62,58.97,,,,,,,,,,Gross Charge Type: Pharmacy
AMBRISENTAN 5 MG TABS,104739,CDM,250,RC,47335023683,NDC,,,facility,both,1,UN,,86.8,65.1,,,,,,,,,,Gross Charge Type: Pharmacy
AMILORIDE 5 MG TABS,1048,CDM,250,RC,574029201,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 4.6 MG/24 HR PT24,104936,CDM,250,RC,78050115,NDC,,,facility,both,1,UN,,59.1,44.32,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 4.6 MG/24 HR PT24,104936,CDM,250,RC,378907093,NDC,,,facility,both,1,UN,,31.2,23.4,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 9.5 MG/24 HR PT24,104937,CDM,250,RC,47781030503,NDC,,,facility,both,1,UN,,40.8,30.6,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 9.5 MG/24 HR PT24,104937,CDM,250,RC,781730931,NDC,,,facility,both,1,UN,,44.35,33.26,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 9.5 MG/24 HR PT24,104937,CDM,250,RC,16714011601,NDC,,,facility,both,1,UN,,26.55,19.91,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,57896094101,NDC,,,facility,both,3,UN,,2.13,1.6,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,57896094101,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,FAMRXNC,HCPCS,904791461,NDC,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,904791461,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,57896094101,NDC,,,facility,both,4,UN,,1.62,1.22,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,FAMRXNC,HCPCS,904791461,NDC,facility,both,3,UN,,2.43,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,FAMRXNC,HCPCS,904791461,NDC,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,904791461,NDC,,,facility,both,1.5,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,904791461,NDC,,,facility,both,4,UN,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,904791461,NDC,,,facility,both,3,UN,,2.43,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,904791461,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,904791461,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,57896094101,NDC,,,facility,both,2,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG TABS,10516,CDM,250,RC,FAMRXNC,HCPCS,904791461,NDC,facility,both,4,UN,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,65162046410,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,904585361,NDC,,,facility,both,1.5,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,65162046410,NDC,,,facility,both,1.5,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,65162046410,NDC,,,facility,both,0.5,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,904585361,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,60687044601,NDC,,,facility,both,2,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,65162046410,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,904585361,NDC,,,facility,both,0.855,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,904585361,NDC,,,facility,both,2,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,904585361,NDC,,,facility,both,0.75,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,60687044601,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG TABS,10518,CDM,250,RC,904585361,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG TABS,10519,CDM,250,RC,65162046510,NDC,,,facility,both,0.8333,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG TABS,10519,CDM,250,RC,65162046510,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG TABS,10519,CDM,250,RC,60687045701,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG TABS,10519,CDM,250,RC,60687045701,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG TABS,10519,CDM,250,RC,65162046510,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG TABS,10520,CDM,250,RC,904585561,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG TABS,10520,CDM,250,RC,65162046610,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG TABS,10520,CDM,250,RC,904585561,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG TABS,10520,CDM,250,RC,60687046801,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG TABS,10520,CDM,250,RC,65162046610,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600121,NDC,facility,both,10,ML,,8.26,6.2,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600121,NDC,facility,both,30,ML,,4.93,3.7,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600121,NDC,facility,both,3,ML,,17.5,13.12,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600121,NDC,facility,both,4,ML,,15.41,11.56,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600121,NDC,facility,both,3.6,ML,,14.5,10.88,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600110,NDC,facility,both,10,ML,,8.26,6.2,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600110,NDC,facility,both,30,ML,,4.93,3.7,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600121,NDC,facility,both,2.8,ML,,16.9,12.68,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600110,NDC,facility,both,25.1,ML,,5.07,3.8,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600110,NDC,facility,both,24.1,ML,,5.14,3.86,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600110,NDC,facility,both,17,ML,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600110,NDC,facility,both,34,ML,,4.74,3.55,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600110,NDC,facility,both,4,ML,,15.41,11.56,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600121,NDC,facility,both,20,ML,,5.76,4.32,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600121,NDC,facility,both,2,ML,,21.68,16.26,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600110,NDC,facility,both,17.6,ML,,5.97,4.47,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 10 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600121,NDC,facility,both,6,ML,,11.59,8.69,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 2 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,641613625,NDC,facility,both,4,ML,,15.75,11.82,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 2 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600125,NDC,facility,both,2,ML,,19.81,14.86,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 2 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,641613625,NDC,facility,both,2.2,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 2 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600125,NDC,facility,both,3,ML,,14.3,10.72,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 2 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,641613625,NDC,facility,both,2,ML,,24.04,18.03,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 2 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600125,NDC,facility,both,4,ML,,14.3,10.72,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 2 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,641613625,NDC,facility,both,3.6,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 2 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,641613625,NDC,facility,both,0.8,ML,,12.68,9.51,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG/ML PE/ML SOLN 2 ML VIAL,105671,CDM,636,RC,Q2009,HCPCS,69600125,NDC,facility,both,2.2,ML,,14.3,10.72,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG PE/ML SOLN 10 ML VIAL,105672,CDM,636,RC,Q2009,HCPCS,69600110,NDC,facility,both,50,ME,,15.41,11.56,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 50 MG PE/ML SOLN 2 ML VIAL,105672,CDM,636,RC,Q2009,HCPCS,641613625,NDC,facility,both,50,ME,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 100 MG CP24,105690,CDM,250,RC,62175048537,NDC,,,facility,both,3,UN,,8.82,6.61,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 100 MG CP24,105690,CDM,250,RC,62175048537,NDC,,,facility,both,1,UN,,14.7,11.02,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 10 MG TABS,10581,CDM,250,RC,69315013301,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 10 MG TABS,10581,CDM,250,RC,69315013301,NDC,,,facility,both,2,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 25 MG TABS,10582,CDM,250,RC,69315013401,NDC,,,facility,both,1,UN,,1.35,1.01,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 50 MG TABS,10583,CDM,250,RC,69315013501,NDC,,,facility,both,1,UN,,7.95,5.96,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 50 MG TABS,10583,CDM,250,RC,69315013501,NDC,,,facility,both,0.5,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 50 MG TABS,10583,CDM,250,RC,69315013501,NDC,,,facility,both,2,UN,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 1 MG/2ML SUSP,105882,CDM,636,RC,J7626,HCPCS,186199004,NDC,facility,both,0.5,ME,,23.24,17.43,,,,,,,,,,Gross Charge Type: Pharmacy
FORMOTEROL 20 MCG/2ML NEBU,105884,CDM,636,RC,J7606,HCPCS,49502060530,NDC,facility,both,2,ML,,21.3,15.98,,,,,,,,,,Gross Charge Type: Pharmacy
FORMOTEROL 20 MCG/2ML NEBU,105884,CDM,636,RC,J7606,HCPCS,93406106,NDC,facility,both,2,ML,,39.8,29.85,,,,,,,,,,Gross Charge Type: Pharmacy
FORMOTEROL 20 MCG/2ML NEBU,105884,CDM,636,RC,J7606,HCPCS,49502060561,NDC,facility,both,2,ML,,21.3,15.98,,,,,,,,,,Gross Charge Type: Pharmacy
IDARUBICIN 1 MG/ML SOLN 10 ML VIAL,105901,CDM,636,RC,J9211,HCPCS,143921801,NDC,facility,both,5,ME,,98.7,74.03,,,,,,,,,,Gross Charge Type: Pharmacy
INDAPAMIDE 2.5 MG TABS,10620,CDM,250,RC,228257111,NDC,,,facility,both,1,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
INDAPAMIDE 2.5 MG TABS,10620,CDM,250,RC,62559051101,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML SOLN 100 ML VIAL,106416,CDM,636,RC,J9060,HCPCS,63323010365,NDC,facility,both,10,ME,,8.32,6.24,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML SOLN 100 ML VIAL,106416,CDM,636,RC,J9060,HCPCS,143950501,NDC,facility,both,10,ME,,11.05,8.29,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML SOLN 100 ML VIAL,106416,CDM,636,RC,J9060,HCPCS,703574811,NDC,facility,both,10,ME,,12.61,9.46,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML SOLN 50 ML VIAL,106416,CDM,636,RC,J9060,HCPCS,143950401,NDC,facility,both,10,ME,,10.85,8.14,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML SOLN 50 ML VIAL,106416,CDM,636,RC,J9060,HCPCS,703574711,NDC,facility,both,10,ME,,10.27,7.71,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML SOLN 50 ML VIAL,106416,CDM,636,RC,J9060,HCPCS,63323010351,NDC,facility,both,10,ME,,9.53,7.15,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML SOLN 50 ML VIAL,106416,CDM,636,RC,J9060,HCPCS,16729028811,NDC,facility,both,10,ME,,15.31,11.48,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG CAPS,10644,CDM,250,RC,50268043015,NDC,,,facility,both,1,UN,,7.95,5.96,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG CAPS,10644,CDM,250,RC,50268043015,NDC,,,facility,both,2,UN,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
Noncdm Charge Record Medical Supplies,1064776_C1757_272,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,23625,17718.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
INDOMETHACIN 50 MG SUPP,10650,CDM,250,RC,69344010233,NDC,,,facility,both,1,UN,,538.45,403.84,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG SUPP,10650,CDM,250,RC,69344010233,NDC,,,facility,both,2,UN,,520.53,390.4,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML SOLN,1067,CDM,250,RC,MHS1ML,HCPCS,517912001,NDC,facility,both,1,ML,,1.22,0.92,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML SOLN,1067,CDM,250,RC,MHS1ML,HCPCS,409434673,NDC,facility,both,1,ML,,1.56,1.17,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML SOLN 20 ML VIAL,1067,CDM,250,RC,MHS1ML,HCPCS,517912001,NDC,facility,both,1,ML,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SOLN,106828,CDM,636,RC,J1932,HCPCS,69097087067,NDC,facility,both,1,ME,,112.26,84.2,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SOLN,106828,CDM,636,RC,J1930,HCPCS,15054112004,NDC,facility,both,1,ME,,196.49,147.37,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG TABS,106944,CDM,250,RC,6022761,NDC,,,facility,both,1,UN,,59.03,44.27,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 30 MG CAPS,107041,CDM,250,RC,31722063031,NDC,,,facility,both,2,UN,,8.98,6.73,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 30 MG CAPS,107041,CDM,250,RC,72205004211,NDC,,,facility,both,1,UN,,11.25,8.44,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 30 MG CAPS,107041,CDM,250,RC,33342025666,NDC,,,facility,both,1,UN,,11.8,8.85,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 30 MG CAPS,107041,CDM,250,RC,33342025666,NDC,,,facility,both,2,UN,,7.78,5.83,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 30 MG CAPS,107041,CDM,250,RC,31722063031,NDC,,,facility,both,1,UN,,13.15,9.86,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 30 MG CAPS,107041,CDM,250,RC,64380079701,NDC,,,facility,both,1,UN,,22,16.5,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 30 MG CAPS,107041,CDM,250,RC,4080285,NDC,,,facility,both,1,UN,,32.55,24.41,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 30 MG CAPS,107041,CDM,250,RC,47781046813,NDC,,,facility,both,1,UN,,25,18.75,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 25 MG/ML IV SOLN,1072,CDM,409592201,NDC,,,,,facility,both,250,ML,,23.78,17.83,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 25 MG/ML IV SOLN,1072,CDM,409592101,NDC,,,,,facility,both,250,ML,,13,9.75,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 25 MG/ML SOLN,1072,CDM,636,RC,J0280,HCPCS,409592201,NDC,facility,both,250,ME,,24.83,18.62,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 25 MG/ML SOLN,1072,CDM,636,RC,J0280,HCPCS,409592101,NDC,facility,both,250,ME,,78.47,58.85,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 25 MG/ML SOLN 20 ML VIAL,1072,CDM,636,RC,J0280,HCPCS,409592201,NDC,facility,both,250,ME,,30.91,23.18,,,,,,,,,,Gross Charge Type: Pharmacy
EPENEPHRINE 0.1 % SOLN 30 ML BOTTLE,10767,CDM,250,RC,MHS1ML,HCPCS,42023010301,NDC,facility,both,30,ML,,12.07,9.05,,,,,,,,,,Gross Charge Type: Pharmacy
EPENEPHRINE 0.1 % SOLN 30 ML BOTTLE,10767,CDM,250,RC,MHS1ML,HCPCS,42023010301,NDC,facility,both,7.5,ML,,12.49,9.37,,,,,,,,,,Gross Charge Type: Pharmacy
EPENEPHRINE 0.1 % SOLN 30 ML BOTTLE,10767,CDM,250,RC,MHS1ML,HCPCS,42023010301,NDC,facility,both,15,ML,,12.56,9.42,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,60687032865,NDC,,,facility,both,2,UN,,14.36,10.77,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,60687032865,NDC,,,facility,both,3,UN,,12.73,9.55,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,65862092127,NDC,,,facility,both,2,UN,,4.66,3.5,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,904670706,NDC,,,facility,both,1,UN,,11.9,8.92,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,65862092127,NDC,,,facility,both,1,UN,,8.44,6.33,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,16714081401,NDC,,,facility,both,3,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,904670706,NDC,,,facility,both,2,UN,,7.88,5.91,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,60687032865,NDC,,,facility,both,1,UN,,19.86,14.9,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,16714081401,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,65862092127,NDC,,,facility,both,3,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,16714081401,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,65862092127,NDC,,,facility,both,4,UN,,2.76,2.07,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG TABS,107988,CDM,250,RC,904670706,NDC,,,facility,both,3,UN,,6.42,4.81,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL 5 MG TABS,108070,CDM,250,RC,60687064111,NDC,,,facility,both,2,UN,,9.52,7.14,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL 5 MG TABS,108070,CDM,250,RC,60687064111,NDC,,,facility,both,0.5,UN,,10.85,8.14,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE STRONG 5 % SOLN 14 ML BOTTLE,10829,CDM,250,RC,48433023015,NDC,,,facility,both,14,ML,,56,42,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG TABS,108293,CDM,250,RC,69367019430,NDC,,,facility,both,2,UN,,25.65,19.24,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG TABS,108293,CDM,250,RC,63739017830,NDC,,,facility,both,2,UN,,14.48,10.86,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG TABS,108293,CDM,250,RC,50268018412,NDC,,,facility,both,2,UN,,17.32,12.99,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG TABS,108293,CDM,250,RC,69367019430,NDC,,,facility,both,1,UN,,30.95,23.21,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG SOLR 1 EACH VIAL,108297,CDM,636,RC,J9305,HCPCS,2764001,NDC,facility,both,10,ME,,207.84,155.88,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 100 MG/ML (10 %) SOLN,108428,CDM,636,RC,J1459,HCPCS,44206043605,NDC,facility,both,500,ME,,88.2,66.15,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 100 MG/ML (10 %) SOLN,108429,CDM,636,RC,J1459,HCPCS,44206043940,NDC,facility,both,500,ME,,87.55,65.66,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 100 MG/ML (10 %) SOLN,108429,CDM,636,RC,J1459,HCPCS,44206043710,NDC,facility,both,500,ME,,87.55,65.66,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN 100 MG/ML (10 %) SOLN,108429,CDM,636,RC,J1459,HCPCS,44206043710,NDC,facility,both,500,ME,,87.12,65.34,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 100 MG/ML (10 %) SOLN,108430,CDM,636,RC,J1459,HCPCS,44206043820,NDC,facility,both,500,ME,,87.55,65.66,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 100 MG/ML (10 %) SOLN,108430,CDM,636,RC,J1459,HCPCS,44206043940,NDC,facility,both,500,ME,,87.55,65.66,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 100 MG/ML (10 %) SOLN 200 ML VIAL,108430,CDM,636,RC,J1459,HCPCS,44206043820,NDC,facility,both,500,ME,,87.55,65.66,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN 100 MG/ML (10 %) SOLN,108430,CDM,636,RC,J1459,HCPCS,44206043820,NDC,facility,both,500,ME,,87.12,65.34,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,406851062,NDC,,,facility,both,1.5,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,42858000210,NDC,,,facility,both,4,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,42858000210,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,42858000210,NDC,,,facility,both,0.5,UN,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,42858000210,NDC,,,facility,both,5,UN,,2.14,1.6,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,42858000210,NDC,,,facility,both,9,UN,,1.68,1.26,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,406851062,NDC,,,facility,both,8,UN,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,406851062,NDC,,,facility,both,3,UN,,2.67,2,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,406851062,NDC,,,facility,both,4,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,10702005601,NDC,,,facility,both,1,UN,,4.87,3.65,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,406851062,NDC,,,facility,both,2,UN,,3.46,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,42858000210,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,10702005601,NDC,,,facility,both,2,UN,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,42858000210,NDC,,,facility,both,1.5,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,406851062,NDC,,,facility,both,1,UN,,5.96,4.47,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,10702005601,NDC,,,facility,both,3,UN,,1.97,1.47,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,42858000210,NDC,,,facility,both,3,UN,,2.83,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE HCL 10 MG TABS,108752,CDM,250,RC,406851062,NDC,,,facility,both,9,UN,,1.51,1.13,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 20 MG CAPS,108954,CDM,250,RC,59417010210,NDC,,,facility,both,2,UN,,27.24,20.43,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 20 MG CAPS,108954,CDM,250,RC,59417010210,NDC,,,facility,both,1,UN,,29.08,21.81,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 20 MG CAPS,108954,CDM,250,RC,59417010210,NDC,,,facility,both,3,UN,,26.68,20.01,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 20 MG CAPS 100 EACH BOTTLE,108954,CDM,250,RC,59417010210,NDC,,,facility,both,1,UN,,24.27,18.2,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-POLYMYXIN-HC 1 % SOLN,10908,CDM,250,RC,61314064610,NDC,,,facility,both,0.266666667,ML,,147.45,110.59,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-POLYMYXIN-HC 1 % SOLN 10 ML BOTTLE,10908,CDM,250,RC,24208063110,NDC,,,facility,both,10,ML,,146.85,110.14,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML SOLN 2 ML VIAL,10912,CDM,636,RC,J1750,HCPCS,23608210,NDC,facility,both,50,ME,,50.42,37.82,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID-CYANOCOBALAMIN-PYRIDOXINE 2.5-25-2 MG TABS,109198,CDM,250,RC,51991038490,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID-CYANOCOBALAMIN-PYRIDOXINE 2.5-25-2 MG TABS,109198,CDM,250,RC,51991038490,NDC,,,facility,both,2,UN,,4.95,3.71,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 20 MG/ML SOLN 5 ML VIAL,109206,CDM,636,RC,J9206,HCPCS,9752903,NDC,facility,both,20,ME,,31.12,23.34,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 20 MG/ML SOLN 5 ML VIAL,109206,CDM,636,RC,J9206,HCPCS,143970101,NDC,facility,both,20,ME,,10.81,8.11,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 20 MG/ML SOLN 5 ML VIAL,109206,CDM,636,RC,J9206,HCPCS,60505612801,NDC,facility,both,20,ME,,22.49,16.87,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 20 MG/ML SOLN 5 ML VIAL,109206,CDM,636,RC,J9206,HCPCS,143958301,NDC,facility,both,20,ME,,9.53,7.15,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 20 MG/ML SOLN 5 ML VIAL,109206,CDM,636,RC,J9206,HCPCS,16714013101,NDC,facility,both,20,ME,,7.32,5.49,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE 50 MG TB24,109225,CDM,250,RC,54040013,NDC,,,facility,both,2,UN,,5.98,4.48,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE 50 MG TB24,109225,CDM,250,RC,60687060721,NDC,,,facility,both,4,UN,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE 50 MG TB24,109225,CDM,250,RC,60687060721,NDC,,,facility,both,2,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE 50 MG TB24,109225,CDM,250,RC,54040013,NDC,,,facility,both,3,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE 50 MG TB24,109225,CDM,250,RC,60687060721,NDC,,,facility,both,1,UN,,11.45,8.59,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE 50 MG TB24,109225,CDM,250,RC,60687060721,NDC,,,facility,both,0.5,UN,,9.55,7.16,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE 50 MG TB24,109225,CDM,250,RC,54040013,NDC,,,facility,both,1,UN,,9.68,7.26,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE 50 MG TB24,109225,CDM,250,RC,54040013,NDC,,,facility,both,4,UN,,3.96,2.97,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 2 MG/ML SOLN,109388,CDM,636,RC,J0744,HCPCS,25021011487,NDC,facility,both,200,ME,,23.28,17.46,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 2 MG/ML SOLN,109388,CDM,636,RC,J0744,HCPCS,25021019287,NDC,facility,both,200,ME,,61.42,46.07,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 100 MCG/ML SOLN,109429,CDM,636,RC,J2354,HCPCS,63323037601,NDC,facility,both,1,ML,,10.71,8.03,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN,109431,CDM,636,RC,J2354,HCPCS,63323037701,NDC,facility,both,0.1,ML,,16.7,12.52,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN,109431,CDM,636,RC,J2354,HCPCS,63323037701,NDC,facility,both,1,ML,,3.99,2.99,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN,109431,CDM,636,RC,J2354,HCPCS,63323037701,NDC,facility,both,0.2,ML,,10.44,7.83,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN,109431,CDM,636,RC,J2354,HCPCS,23155068931,NDC,facility,both,0.2,ML,,16.94,12.7,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN,109431,CDM,636,RC,J2354,HCPCS,641617610,NDC,facility,both,0.2,ML,,10.29,7.72,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN,109431,CDM,636,RC,J2354,HCPCS,63323037701,NDC,facility,both,0.4,ML,,7.32,5.49,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN,109431,CDM,636,RC,J2354,HCPCS,63323037701,NDC,facility,both,0.3,ML,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN 1 ML VIAL,109431,CDM,636,RC,J2354,HCPCS,63323037701,NDC,facility,both,0.2,ML,,10.44,7.83,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN 1 ML VIAL,109431,CDM,636,RC,J2354,HCPCS,63323037701,NDC,facility,both,1,ML,,3.99,2.99,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN 1 ML VIAL,109431,CDM,636,RC,J2354,HCPCS,63323037701,NDC,facility,both,0.1,ML,,16.7,12.52,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN 1 ML VIAL,109431,CDM,636,RC,J2354,HCPCS,23155068931,NDC,facility,both,1,ML,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN 1 ML VIAL,109431,CDM,636,RC,J2354,HCPCS,23155068931,NDC,facility,both,0.1,ML,,25,18.75,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN 1 ML VIAL,109431,CDM,636,RC,J2354,HCPCS,641617610,NDC,facility,both,1,ML,,3.94,2.95,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE 500 MCG/ML SOLN 1 ML VIAL,109431,CDM,636,RC,J2354,HCPCS,641617610,NDC,facility,both,0.1,ML,,16.55,12.41,,,,,,,,,,Gross Charge Type: Pharmacy
ISONIAZID 300 MG TABS,11010,CDM,250,RC,60687055301,NDC,,,facility,both,1,UN,,10.05,7.54,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SOLN,110677,CDM,636,RC,J2212,HCPCS,65649055107,NDC,facility,both,0.1,ME,,3.91,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SOLN,110677,CDM,636,RC,J2212,HCPCS,65649055102,NDC,facility,both,0.1,ME,,3.79,2.84,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG TABS,11080,CDM,250,RC,50268044815,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG TABS,11080,CDM,250,RC,68084008201,NDC,,,facility,both,0.5,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG TABS,11080,CDM,250,RC,68084008201,NDC,,,facility,both,1,UN,,9.7,7.28,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG TABS,11080,CDM,250,RC,50268044815,NDC,,,facility,both,0.5,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG TABS,11080,CDM,250,RC,50268044815,NDC,,,facility,both,3,UN,,4.02,3.01,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG TABS,11080,CDM,250,RC,50268044815,NDC,,,facility,both,2,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG TABS,11081,CDM,250,RC,63739036710,NDC,,,facility,both,2,UN,,5.52,4.14,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG TABS,11081,CDM,250,RC,63739036710,NDC,,,facility,both,1,UN,,8.08,6.06,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Med/Surg Private,1110000001,CDM,111,RC,,,,,facility,both,,,,1811,1358.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Room Telemetry Med- Surg Private,1110000002,CDM,111,RC,,,,,facility,both,,,,2256,1692,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Room Obstetrics Private,1120000001,CDM,112,RC,,,,,facility,both,,,,1978,1483.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
BENZOCAINE 20 % GEL 11.9 G TUBE,11232,CDM,250,RC,10310028313,NDC,,,facility,both,11.9,GR,,13.9,10.42,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % SOLN,11242,CDM,250,RC,283061026,NDC,,,facility,both,2,UN,,31.21,23.41,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % SOLN,11242,CDM,250,RC,283061026,NDC,,,facility,both,1,UN,,48.01,36.01,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % SOLN,11242,CDM,250,RC,283061043,NDC,,,facility,both,1,UN,,55.65,41.74,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.08 MG/ML SOLN,112442,CDM,636,RC,J2785,HCPCS,409140101,NDC,facility,both,0.1,ME,,176.44,132.33,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.08 MG/ML SOLN,112442,CDM,636,RC,J2785,HCPCS,641625301,NDC,facility,both,0.1,ME,,29.56,22.17,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.08 MG/ML SOLN,112442,CDM,636,RC,J2785,HCPCS,469650189,NDC,facility,both,0.1,ME,,147.85,110.89,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.08 MG/ML SOLN,112442,CDM,636,RC,J2785,HCPCS,71288020185,NDC,facility,both,0.1,ME,,107.99,80.99,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5ML IV SOLN,112442,CDM,71288020185,NDC,,,,,facility,both,0.1,ML,,110.3,82.72,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5ML IV SOLN,112442,CDM,409140101,NDC,,,,,facility,both,0.1,ML,,166.07,124.55,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5ML IV SOLN,112442,CDM,469650189,NDC,,,,,facility,both,0.1,ML,,148.09,111.07,,,,,,,,,,Gross Charge Type: Pharmacy
ALVIMOPAN 12 MG CAPS,112444,CDM,250,RC,591231215,NDC,,,facility,both,1,UN,,246.7,185.02,,,,,,,,,,Gross Charge Type: Pharmacy
DTAP-IPV-HIB SUSR,112575,CDM,636,RC,90698,HCPCS,49281051105,NDC,facility,both,0.5,ML,,218.95,164.21,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL 5 MG/5 ML SOLN,112580,CDM,250,RC,MHS1ML,HCPCS,36000003310,NDC,facility,both,1,ML,,5.62,4.21,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL 5 MG/5 ML SOLN,112580,CDM,250,RC,MHS1ML,HCPCS,72572042001,NDC,facility,both,1,ML,,6.16,4.62,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL 5 MG/5 ML SOLN,112580,CDM,250,RC,MHS1ML,HCPCS,409177805,NDC,facility,both,1,ML,,5.63,4.22,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 4 MG/4ML SOLN,112608,CDM,636,RC,J1626,HCPCS,63323031801,NDC,facility,both,0.1,ME,,4.58,3.44,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 10 MG TABS,1127,CDM,250,RC,16714025701,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 10 MG TABS,1127,CDM,250,RC,51079013120,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 10 MG TABS,1127,CDM,250,RC,16714025701,NDC,,,facility,both,2,UN,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 10 MG TABS,1127,CDM,250,RC,16714025701,NDC,,,facility,both,4,UN,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 10 MG TABS,1127,CDM,250,RC,16714025701,NDC,,,facility,both,1.5,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 10 MG TABS,1127,CDM,250,RC,16714025701,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 10 MG TABS,1127,CDM,250,RC,16714025701,NDC,,,facility,both,3,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 10 MG TABS,1127,CDM,250,RC,16714025701,NDC,,,facility,both,2.5,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA 1000 MCG/ML SOLR,112841,CDM,636,RC,J7212,HCPCS,169720101,NDC,facility,both,1,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA 1000 MCG/ML SOLR,112842,CDM,636,RC,J7189,HCPCS,169720201,NDC,facility,both,1,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA 1000 MCG/ML SOLR,112842,CDM,636,RC,J7189,HCPCS,169720201,NDC,facility,both,2.7,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA 1000 MCG/ML SOLR,112842,CDM,636,RC,J7189,HCPCS,169720201,NDC,facility,both,3,UN,,5.54,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 25 MG TABS,1130,CDM,250,RC,60687043301,NDC,,,facility,both,0.5,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 25 MG TABS,1130,CDM,250,RC,60687043301,NDC,,,facility,both,1,UN,,8.21,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 25 MG TABS,1130,CDM,250,RC,60687043301,NDC,,,facility,both,4,UN,,2.76,2.07,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 25 MG TABS,1130,CDM,250,RC,60687043301,NDC,,,facility,both,2,UN,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 25 MG TABS,1130,CDM,250,RC,60687043301,NDC,,,facility,both,1.5,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 25 MG TABS,1130,CDM,250,RC,60687043301,NDC,,,facility,both,3,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Pediatrics Private,1130000001,CDM,113,RC,,,,,facility,both,,,,2329,1746.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
BARIUM SULFATE 0.1 % SUSP,113037,CDM,250,RC,MHS10ML,HCPCS,32909092703,NDC,facility,both,10,ML,,0.31,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML SOLN,113069,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,both,30,ME,,6.37,4.78,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML SOLN,113069,CDM,636,RC,J0282,HCPCS,143987525,NDC,facility,both,30,ME,,7.58,5.68,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML SOLN 3 ML VIAL,113069,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,both,30,ME,,7.43,5.57,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML SOLN 3 ML VIAL,113069,CDM,636,RC,J0282,HCPCS,143987525,NDC,facility,both,30,ME,,7.58,5.68,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003915,NDC,,,facility,both,4,UN,,2.74,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70710122701,NDC,,,facility,both,0.5,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,781148801,NDC,,,facility,both,3,UN,,3.78,2.84,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,781148801,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,781148801,NDC,,,facility,both,2.5,UN,,3.58,2.69,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003915,NDC,,,facility,both,0.5,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70710122701,NDC,,,facility,both,1.5,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70756020311,NDC,,,facility,both,4,UN,,2.31,1.73,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70756020311,NDC,,,facility,both,2.5,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003911,NDC,,,facility,both,6,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70756020311,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,781148801,NDC,,,facility,both,4,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70756020311,NDC,,,facility,both,1.5,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70710122701,NDC,,,facility,both,4,UN,,2.84,2.13,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70710122701,NDC,,,facility,both,2.5,UN,,3.33,2.5,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,781148801,NDC,,,facility,both,0.5,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,781148801,NDC,,,facility,both,2,UN,,5.08,3.81,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003915,NDC,,,facility,both,1.5,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70756020311,NDC,,,facility,both,2,UN,,3.96,2.97,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003911,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70756020311,NDC,,,facility,both,3,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70710122701,NDC,,,facility,both,1,UN,,8.09,6.07,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70710122701,NDC,,,facility,both,3,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003911,NDC,,,facility,both,2,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70710122701,NDC,,,facility,both,2,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003915,NDC,,,facility,both,3,UN,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003915,NDC,,,facility,both,2,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,781148801,NDC,,,facility,both,1.5,UN,,4.78,3.58,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003911,NDC,,,facility,both,3,UN,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70756020311,NDC,,,facility,both,6,UN,,1.68,1.26,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,70756020311,NDC,,,facility,both,1,UN,,4.67,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 50 MG TABS,1131,CDM,250,RC,50268003915,NDC,,,facility,both,1,UN,,5.64,4.23,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (5 ML) SOLN,113686,CDM,636,RC,J2250,HCPCS,409230505,NDC,facility,both,1,ME,,19.48,14.61,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (5 ML) SOLN,113686,CDM,636,RC,J2250,HCPCS,409230517,NDC,facility,both,1,ME,,33.4,25.05,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (5 ML) SOLN,113686,CDM,636,RC,J2250,HCPCS,641605910,NDC,facility,both,1,ME,,15.31,11.48,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 5 MG/ML SOLN 10 ML VIAL,113690,CDM,636,RC,J2250,HCPCS,641606010,NDC,facility,both,1,ME,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 5 MG/ML SOLN 10 ML VIAL,113690,CDM,636,RC,J2250,HCPCS,409259605,NDC,facility,both,1,ME,,1.13,0.85,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.32,UN,,246.98,185.24,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.76,UN,,235.22,176.41,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.212,UN,,275.76,206.82,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,1.976,UN,,232.39,174.3,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,1.564,UN,,229.92,172.44,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.36,UN,,235.22,176.41,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,1.68,UN,,246.98,185.23,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.788,UN,,243.28,182.46,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,1.9,UN,,232.77,174.57,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.44,UN,,235.22,176.41,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.564,UN,,221.11,165.83,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.752,UN,,234.29,175.72,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.64,UN,,235.22,176.41,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.56,UN,,235.22,176.41,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,5.6,UN,,235.22,176.41,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.58,UN,,227.38,170.53,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.324,UN,,250.07,187.55,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,1,UN,,238.29,178.71,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.1,UN,,373.12,279.84,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,2,UN,,239.31,179.48,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,1.56,UN,,235.22,176.41,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.436,UN,,256.39,192.29,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,6,UN,,235.22,176.41,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.42,UN,,246.98,185.24,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.792,UN,,232.86,174.65,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.24,UN,,238.62,178.97,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.404,UN,,237.57,178.18,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,1.676,UN,,246.39,184.79,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.4,UN,,235.22,176.42,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,1.58,UN,,232.28,174.21,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.248,UN,,244.32,183.24,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,2.596,UN,,234.85,176.14,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.208,UN,,266.88,200.16,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,113720,CDM,636,RC,J2796,HCPCS,55513022101,NDC,facility,both,0.9,UN,,230.1,172.58,,,,,,,,,,Gross Charge Type: Pharmacy
GADOXETATE DISODIUM 0.25 MOL/L SOLN,113725,CDM,636,RC,A9581,HCPCS,50419032005,NDC,facility,both,1,ML,,42.19,31.65,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Psychiatric Private,1140000001,CDM,114,RC,,,,,facility,both,,,,2608,1956,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
KETOROLAC 0.5 % SOLN 5 ML BOTTLE,11417,CDM,250,RC,61314012605,NDC,,,facility,both,5,ML,,40.7,30.52,,,,,,,,,,Gross Charge Type: Pharmacy
MITOXANTRONE 2 MG/ML CONC 10 ML VIAL,114257,CDM,636,RC,J9293,HCPCS,63323013210,NDC,facility,both,5,ME,,86.61,64.96,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM ER 500 MG TB24,114341,CDM,250,RC,68180011707,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM ER 500 MG TB24,114341,CDM,250,RC,68180011707,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 150 MG/ML SUSP,11435,CDM,636,RC,J1050,HCPCS,55150032901,NDC,facility,both,1,ME,,0.57,0.43,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 150 MG/ML SUSP,11435,CDM,636,RC,J1050,HCPCS,66993037083,NDC,facility,both,1,ME,,15.04,11.28,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 150 MG/ML SUSP,11435,CDM,636,RC,J1050,HCPCS,67457088701,NDC,facility,both,1,ME,,0.91,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 150 MG/ML SUSP,11435,CDM,636,RC,J1050,HCPCS,548540025,NDC,facility,both,1,ME,,0.5,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 150 MG/ML SUSP,11435,CDM,636,RC,J1050,HCPCS,70121146702,NDC,facility,both,1,ME,,0.45,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,11435,CDM,70121146702,NDC,,,,,facility,both,1,ML,,1.07,0.8,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,11435,CDM,55150032901,NDC,,,,,facility,both,1,ML,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,11435,CDM,9074630,NDC,,,,,facility,both,1,ML,,1.3,0.98,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,11435,CDM,548540000,NDC,,,,,facility,both,1,ML,,1.12,0.84,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,11435,CDM,66993037083,NDC,,,,,facility,both,1,ML,,15.04,11.28,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,11435,CDM,9737611,NDC,,,,,facility,both,1,ML,,1.14,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,11435,CDM,548540025,NDC,,,,,facility,both,1,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,11435,CDM,67457088701,NDC,,,,,facility,both,1,ML,,0.91,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,11435,CDM,9074635,NDC,,,,,facility,both,1,ML,,1.3,0.98,,,,,,,,,,Gross Charge Type: Pharmacy
MENTHOL 2.5 % GEL 57 G TUBE,114406,CDM,250,RC,74300008197,NDC,,,facility,both,57,GR,,76.25,57.19,,,,,,,,,,Gross Charge Type: Pharmacy
SORBITOL 70 % SOLN 473 ML BOTTLE,114434,CDM,250,RC,46287050001,NDC,,,facility,both,100,ML,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,60687040583,NDC,facility,both,1,ML,,4.23,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,487020103,NDC,facility,both,1,ML,,4.05,3.04,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,487020160,NDC,facility,both,1,ML,,4.03,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,76204060001,NDC,facility,both,1,ML,,4.18,3.14,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,69097017353,NDC,facility,both,1,ML,,4.17,3.12,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,378967193,NDC,facility,both,1,ML,,4.33,3.25,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,378967130,NDC,facility,both,1,ML,,4.3,3.23,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,J7620,HCPCS,487020101,NDC,facility,both,1,ML,,9.79,7.34,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,487020101,NDC,facility,both,1,ML,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,69097084064,NDC,facility,both,1,ML,,4.17,3.12,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,76204060030,NDC,facility,both,1,ML,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL-IPRATROPIUM 2.5-0.5 MG/3ML SOLN,114438,CDM,250,RC,MHS1ML,HCPCS,69097084087,NDC,facility,both,1,ML,,4.63,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,114438,CDM,487020101,NDC,,,,,facility,both,1,ML,,30.1,22.58,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,114438,CDM,487020101,NDC,,,,,facility,both,1,ML,,10.46,7.85,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,11472,CDM,250,RC,MHS1ML,HCPCS,60505056000,NDC,facility,both,1,ML,,10.65,7.99,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,11472,CDM,250,RC,MHS1ML,HCPCS,24208043405,NDC,facility,both,1,ML,,11.81,8.86,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,11472,CDM,250,RC,MHS1ML,HCPCS,70756060730,NDC,facility,both,1,ML,,9.13,6.85,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,11472,CDM,250,RC,MHS1ML,HCPCS,64980051505,NDC,facility,both,1,ML,,11.9,8.92,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOLN,11478,CDM,250,RC,MHS1ML,HCPCS,67457018199,NDC,facility,both,1,ML,,17.57,13.18,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOLN,11478,CDM,250,RC,MHS1ML,HCPCS,55150043801,NDC,facility,both,1,ML,,5.36,4.02,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOLN,11478,CDM,250,RC,MHS1ML,HCPCS,42023011310,NDC,facility,both,1,ML,,4.49,3.37,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOLN,11478,CDM,250,RC,MHS1ML,HCPCS,55150043810,NDC,facility,both,1,ML,,8.79,6.59,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOLN,11478,CDM,250,RC,MHS1ML,HCPCS,25021068220,NDC,facility,both,1,ML,,8.17,6.12,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOLN 20 ML VIAL,11478,CDM,250,RC,MHS1ML,HCPCS,55150043810,NDC,facility,both,1,ML,,3.77,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOLN 20 ML VIAL,11478,CDM,250,RC,MHS1ML,HCPCS,42023011310,NDC,facility,both,1,ML,,4.49,3.37,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML SOLN,11479,CDM,250,RC,MHS1ML,HCPCS,42023011510,NDC,facility,both,1,ML,,14.27,10.7,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML SOLN,11479,CDM,250,RC,MHS1ML,HCPCS,409205105,NDC,facility,both,1,ML,,30.17,22.62,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML SOLN 5 ML VIAL,11479,CDM,250,RC,MHS1ML,HCPCS,409205105,NDC,facility,both,1,ML,,10.65,7.99,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML SOLN 5 ML VIAL,11479,CDM,250,RC,MHS1ML,HCPCS,42023011510,NDC,facility,both,1,ML,,14.27,10.7,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/ML SOLN,11480,CDM,250,RC,MHS1ML,HCPCS,54355344,NDC,facility,both,1,ML,,31.04,23.28,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/ML SOLN 10 ML VIAL,11480,CDM,250,RC,MHS1ML,HCPCS,143950810,NDC,facility,both,1,ML,,4.64,3.48,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/ML SOLN 10 ML VIAL,11480,CDM,250,RC,MHS1ML,HCPCS,42023011410,NDC,facility,both,1,ML,,5.33,4,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/ML SOLN 2 ML SYRINGE,11480,CDM,250,RC,MHS1ML,HCPCS,54355344,NDC,facility,both,1,ML,,32.75,24.56,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN,115016,CDM,636,RC,J2405,HCPCS,143989010,NDC,facility,both,1,ME,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN,115016,CDM,636,RC,J2405,HCPCS,23155054742,NDC,facility,both,1,ME,,6.96,5.22,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN,115016,CDM,636,RC,J2405,HCPCS,641607825,NDC,facility,both,1,ME,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN,115016,CDM,636,RC,J2405,HCPCS,641608025,NDC,facility,both,1,ME,,6.89,5.16,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN,115016,CDM,636,RC,J2405,HCPCS,63323037302,NDC,facility,both,1,ME,,2.89,2.17,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN,115016,CDM,636,RC,J2405,HCPCS,36000001225,NDC,facility,both,1,ME,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN,115016,CDM,636,RC,J2405,HCPCS,409475503,NDC,facility,both,1,ME,,8.29,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN,115016,CDM,636,RC,J2405,HCPCS,60505613005,NDC,facility,both,1,ME,,6.59,4.94,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN 2 ML VIAL,115016,CDM,636,RC,J2405,HCPCS,641608025,NDC,facility,both,1,ME,,2.26,1.7,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN 2 ML VIAL,115016,CDM,636,RC,J2405,HCPCS,60505613005,NDC,facility,both,1,ME,,2.38,1.79,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN 2 ML VIAL,115016,CDM,636,RC,J2405,HCPCS,641607825,NDC,facility,both,1,ME,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 2 MG/ML SOLN 2 ML VIAL,115016,CDM,636,RC,J2405,HCPCS,23155054742,NDC,facility,both,1,ME,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/2ML IJ SOLN,115016,CDM,23155054742,NDC,,,,,facility,both,1,ML,,7.3,5.47,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/2ML IJ SOLN,115016,CDM,641607825,NDC,,,,,facility,both,1,ML,,6.54,4.9,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/2ML IJ SOLN,115016,CDM,641607825,NDC,,,,,facility,both,1,ML,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG LOZG,115061,CDM,250,RC,63824071316,NDC,,,facility,both,2,UN,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG LOZG,115061,CDM,250,RC,904625549,NDC,,,facility,both,2,UN,,1.8,1.35,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG LOZG,115061,CDM,250,RC,904625549,NDC,,,facility,both,1,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG LOZG,115061,CDM,250,RC,63824071316,NDC,,,facility,both,1,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG CAPS,1157,CDM,250,RC,16714029801,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NS 40-0.83 MG/200ML-% SOLN,115754,CDM,636,RC,J2404,HCPCS,43066001610,NDC,facility,both,0.1,ME,,1.75,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NS 40-0.83 MG/200ML-% SOLN,115754,CDM,250,RC,43066001610,NDC,,,facility,both,0.1,ME,,638.01,478.51,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG CAPS,1158,CDM,250,RC,16714029903,NDC,,,facility,both,2,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG CAPS,1158,CDM,250,RC,16714029903,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG CAPS,1158,CDM,250,RC,16714029903,NDC,,,facility,both,4,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG CAPS,1158,CDM,250,RC,57237003101,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 15 MG/ML SOLN,115966,CDM,250,RC,MHS2.5ML,HCPCS,54838001150,NDC,facility,both,2.5,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Detoxification Private,1160000001,CDM,116,RC,,,,,facility,both,,,,2779,2084.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
ROCURONIUM 10 MG/ML SOLN,116084,CDM,250,RC,MHS5ml,HCPCS,781322095,NDC,facility,both,5,ML,,68.28,51.21,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116084,CDM,250,RC,MHS5ml,HCPCS,55150022505,NDC,facility,both,5,ML,,61.85,46.39,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116084,CDM,250,RC,MHS5ml,HCPCS,67457022805,NDC,facility,both,5,ML,,52.58,39.44,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116084,CDM,250,RC,MHS5ml,HCPCS,409318910,NDC,facility,both,5,ML,,43.77,32.83,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116084,CDM,250,RC,MHS5ml,HCPCS,63323042605,NDC,facility,both,5,ML,,56.48,42.36,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116084,CDM,250,RC,MHS5ml,HCPCS,25021066205,NDC,facility,both,5,ML,,45.86,34.39,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116084,CDM,250,RC,MHS5ml,HCPCS,39822420002,NDC,facility,both,5,ML,,68,51,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116084,CDM,250,RC,MHS5ml,HCPCS,43066000710,NDC,facility,both,5,ML,,53.16,39.87,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,781322092,NDC,,,facility,both,7,ML,,78.25,58.69,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,409318910,NDC,,,facility,both,8.04,ML,,33.8,25.35,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,63323042605,NDC,,,facility,both,8,ML,,41.1,30.82,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,781322092,NDC,,,facility,both,15,ML,,46.8,35.1,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,781322092,NDC,,,facility,both,8,ML,,78.25,58.69,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,409318910,NDC,,,facility,both,15,ML,,24.02,18.01,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,409318910,NDC,,,facility,both,7.5,ML,,33.62,25.22,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,781322092,NDC,,,facility,both,5,ML,,78.25,58.69,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,781322092,NDC,,,facility,both,2,ML,,78.25,58.69,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,67457022805,NDC,,,facility,both,5,ML,,71.15,53.36,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,409318910,NDC,,,facility,both,5.78,ML,,33.08,24.81,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,781322092,NDC,,,facility,both,9.6,ML,,78.25,58.69,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,43066000710,NDC,,,facility,both,10,ML,,34.42,25.82,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,409318910,NDC,,,facility,both,10,ML,,34.42,25.82,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,781322095,NDC,,,facility,both,10,ML,,44.68,33.51,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,55150022505,NDC,,,facility,both,15,ML,,31.52,23.64,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,409318910,NDC,,,facility,both,12,ML,,23.38,17.54,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,781322092,NDC,,,facility,both,10,ML,,78.25,58.69,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,409318910,NDC,,,facility,both,7,ML,,33.45,25.09,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,409318910,NDC,,,facility,both,5,ML,,65.65,49.24,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,409318910,NDC,,,facility,both,8,ML,,33.78,25.33,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML SOLN,116085,CDM,250,RC,67457022805,NDC,,,facility,both,10,ML,,39.72,29.79,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5ML SUSR,1161,CDM,250,RC,MHS1ML,HCPCS,781604158,NDC,facility,both,1,ML,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TB24,116479,CDM,250,RC,904680161,NDC,,,facility,both,2,UN,,5.48,4.11,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TB24,116479,CDM,250,RC,50228038060,NDC,,,facility,both,1,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TB24,116479,CDM,250,RC,904680161,NDC,,,facility,both,4,UN,,3.49,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TB24,116479,CDM,250,RC,904680161,NDC,,,facility,both,3,UN,,4.17,3.12,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TB24,116479,CDM,250,RC,904680161,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
L-LYSINE 500 MG TABS,11659,CDM,250,RC,30768000830,NDC,,,facility,both,2,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
L-LYSINE 500 MG TABS,11659,CDM,250,RC,30768000830,NDC,,,facility,both,1,UN,,8.3,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,11708,CDM,636,RC,J7120,HCPCS,264775000,NDC,facility,both,1000,ML,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,11708,CDM,636,RC,J7120,HCPCS,409795303,NDC,facility,both,1000,ML,,24.7,18.52,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,11708,CDM,636,RC,J7120,HCPCS,990795309,NDC,facility,both,1000,ML,,23.68,17.76,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,11708,CDM,636,RC,J7120,HCPCS,338011703,NDC,facility,both,1000,ML,,15.87,11.9,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,11708,CDM,636,RC,J7120,HCPCS,338011704,NDC,facility,both,1000,ML,,17.38,13.03,,,,,,,,,,Gross Charge Type: Pharmacy
"LACTATED RINGERS SOLN 1,000 ML FLEX CONT",11708,CDM,636,RC,J7120,HCPCS,338011704,NDC,facility,both,1000,ML,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
"LACTATED RINGERS SOLN 1,000 ML FLEX CONT",11708,CDM,636,RC,J7120,HCPCS,990795309,NDC,facility,both,1000,ML,,23.7,17.78,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS (ACIDOPHILUS AND BULGARICUS) PACK,11714,CDM,250,RC,64980014612,NDC,,,facility,both,1,UN,,11.15,8.36,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS (ACIDOPHILUS AND BULGARICUS) PACK,11714,CDM,250,RC,8290236712,NDC,,,facility,both,1,UN,,10.4,7.8,,,,,,,,,,Gross Charge Type: Pharmacy
FESOTERODINE 4 MG TB24,117183,CDM,250,RC,69024230,NDC,,,facility,both,1,UN,,29.35,22.01,,,,,,,,,,Gross Charge Type: Pharmacy
FESOTERODINE 4 MG TB24,117183,CDM,250,RC,65862076630,NDC,,,facility,both,1,UN,,9.65,7.24,,,,,,,,,,Gross Charge Type: Pharmacy
FESOTERODINE 4 MG TB24,117183,CDM,250,RC,65862076630,NDC,,,facility,both,2,UN,,5.78,4.33,,,,,,,,,,Gross Charge Type: Pharmacy
SILODOSIN 4 MG CAPS,117185,CDM,250,RC,59651009530,NDC,,,facility,both,2,UN,,5.98,4.48,,,,,,,,,,Gross Charge Type: Pharmacy
SILODOSIN 4 MG CAPS,117185,CDM,250,RC,31722063530,NDC,,,facility,both,1,UN,,9.85,7.39,,,,,,,,,,Gross Charge Type: Pharmacy
SILODOSIN 4 MG CAPS,117185,CDM,250,RC,59651009530,NDC,,,facility,both,1,UN,,9.57,7.18,,,,,,,,,,Gross Charge Type: Pharmacy
SILODOSIN 4 MG CAPS,117185,CDM,250,RC,31722063530,NDC,,,facility,both,2,UN,,5.98,4.48,,,,,,,,,,Gross Charge Type: Pharmacy
SILODOSIN 8 MG CAPS,117186,CDM,250,RC,68180074106,NDC,,,facility,both,1,UN,,9.85,7.39,,,,,,,,,,Gross Charge Type: Pharmacy
SILODOSIN 8 MG CAPS,117186,CDM,250,RC,59651009690,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
SILODOSIN 8 MG CAPS,117186,CDM,250,RC,59651009630,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG TABS,117323,CDM,250,RC,60687053811,NDC,,,facility,both,1.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG TABS,117323,CDM,250,RC,64764091830,NDC,,,facility,both,2,UN,,22.62,16.97,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG TABS,117323,CDM,250,RC,64764091830,NDC,,,facility,both,1,UN,,27.75,20.81,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG TABS,117323,CDM,250,RC,60687053811,NDC,,,facility,both,2,UN,,7.38,5.53,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG TABS,117323,CDM,250,RC,60687053811,NDC,,,facility,both,1,UN,,11.35,8.51,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG TABS,117323,CDM,250,RC,72578013606,NDC,,,facility,both,2,UN,,4.83,3.63,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG TABS,117323,CDM,250,RC,72578013606,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 0.75 % CREA 45 G TUBE,11736,CDM,250,RC,mhs1gm,HCPCS,66993096045,NDC,facility,both,1,GM,,5.84,4.38,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 20 MG/ML SOLN 5 ML VIAL,117550,CDM,636,RC,J9100,HCPCS,61703030538,NDC,facility,both,100,ME,,17.13,12.85,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX ACETATE 80 MG SOLR,117552,CDM,636,RC,J9155,HCPCS,55566830301,NDC,facility,both,1,ME,,21.31,15.98,,,,,,,,,,Gross Charge Type: Pharmacy
SOD BICARB-CITRIC AC-SIMETH 2.21-1.53-0.04 G PACK,117644,CDM,250,RC,10361079301,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 105 % SUSP,117647,CDM,250,RC,MHS1ML,HCPCS,32909016755,NDC,facility,both,1,ML,,0.02,0.01,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 12 MG/ML SOLN,117691,CDM,637,RC,J3030,HCPCS,55150017301,NDC,facility,both,6,ME,,60.35,45.26,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 12 MG/ML SOLN,117691,CDM,637,RC,J3030,HCPCS,143963805,NDC,facility,both,6,ME,,92.65,69.49,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 12 MG/ML SOLN,117691,CDM,636,RC,J3030,HCPCS,55150017301,NDC,facility,both,6,ME,,56.94,42.7,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,117691,CDM,55150017301,NDC,,,,,facility,both,6,ML,,140.14,105.1,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247735,NDC,,,facility,both,3,UN,,23.9,17.92,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,16714054801,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,904724468,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,904724468,NDC,,,facility,both,3,UN,,3.61,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247760,NDC,,,facility,both,1,UN,,28.38,21.29,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,16714054801,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247735,NDC,,,facility,both,1,UN,,28.95,21.71,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247735,NDC,,,facility,both,6,UN,,21.12,15.84,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,904724468,NDC,,,facility,both,4,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,904724468,NDC,,,facility,both,6,UN,,2.87,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247760,NDC,,,facility,both,0.5,UN,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247735,NDC,,,facility,both,2,UN,,23.87,17.9,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,16714054801,NDC,,,facility,both,4,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247735,NDC,,,facility,both,4,UN,,22.33,16.75,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,16714054801,NDC,,,facility,both,0.5,UN,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,904724468,NDC,,,facility,both,2,UN,,4.58,3.44,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247760,NDC,,,facility,both,2,UN,,26.23,19.67,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,904724468,NDC,,,facility,both,0.75,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247760,NDC,,,facility,both,4,UN,,24.92,18.69,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 50 MG TABS,117882,CDM,250,RC,131247760,NDC,,,facility,both,3,UN,,25.16,18.87,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML SOLN,117886,CDM,636,RC,C9254,HCPCS,25021079120,NDC,facility,both,1,ME,,0.94,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML SOLN,117886,CDM,636,RC,C9254,HCPCS,131181067,NDC,facility,both,1,ME,,1.51,1.13,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML SOLN 20 ML VIAL,117886,CDM,636,RC,C9254,HCPCS,131181067,NDC,facility,both,1,ME,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML SOLN 20 ML VIAL,117886,CDM,636,RC,C9254,HCPCS,25021079120,NDC,facility,both,1,ME,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 6.25 MG/5ML SOLN,118145,CDM,250,RC,60432060816,NDC,,,facility,both,5,ML,,5.5,4.12,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 60 MG/2 ML SOLN,118251,CDM,636,RC,J1885,HCPCS,72266011901,NDC,facility,both,15,ME,,15.5,11.63,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 60 MG/2 ML SOLN,118251,CDM,636,RC,J1885,HCPCS,63323016202,NDC,facility,both,15,ME,,9.54,7.16,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 60 MG/2 ML SOLN,118251,CDM,636,RC,J1885,HCPCS,76045010520,NDC,facility,both,15,ME,,28.8,21.6,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 60 MG/2 ML SOLN,118251,CDM,636,RC,J1885,HCPCS,63323016203,NDC,facility,both,15,ME,,15.81,11.86,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 60 MG/2 ML SOLN,118251,CDM,636,RC,J1885,HCPCS,409379619,NDC,facility,both,15,ME,,18.18,13.63,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 60 MG/2 ML SOLN,118251,CDM,636,RC,J1885,HCPCS,72611072525,NDC,facility,both,15,ME,,7.17,5.38,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN,118251,CDM,63323016203,NDC,,,,,facility,both,15,ML,,8.59,6.44,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN,118251,CDM,72266011901,NDC,,,,,facility,both,15,ML,,10.91,8.18,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN,118251,CDM,72611072525,NDC,,,,,facility,both,15,ML,,5.73,4.3,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN,118251,CDM,63323016202,NDC,,,,,facility,both,15,ML,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN,118251,CDM,72611072501,NDC,,,,,facility,both,15,ML,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SOLR,1185,CDM,636,RC,J0290,HCPCS,781340495,NDC,facility,both,500,ME,,12.04,9.03,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SOLR 1 EACH VIAL,1185,CDM,636,RC,J0290,HCPCS,781340495,NDC,facility,both,500,ME,,18.96,14.22,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SOLR 1 EACH VIAL,1185,CDM,636,RC,J0290,HCPCS,25021013610,NDC,facility,both,500,ME,,20.48,15.36,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,2.4,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042501,NDC,,,facility,both,5,ML,,51.95,38.96,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,1,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641921710,NDC,,,facility,both,3,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,7,ML,,23.28,17.46,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042510,NDC,,,facility,both,2,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042510,NDC,,,facility,both,3,ML,,41.2,30.9,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,3,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,4.4,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,4.55,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641921710,NDC,,,facility,both,2,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,4,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641921710,NDC,,,facility,both,5,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042501,NDC,,,facility,both,3,ML,,41.2,30.9,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042510,NDC,,,facility,both,1,ML,,30.4,22.8,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,3.6,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641921710,NDC,,,facility,both,1,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,3.8,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,1.5,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,4.2,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042501,NDC,,,facility,both,4,ML,,46.55,34.91,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,3.2,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,1.4,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042510,NDC,,,facility,both,4,ML,,46.55,34.91,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042510,NDC,,,facility,both,5,ML,,51.95,38.96,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,6,ML,,23.28,17.46,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042510,NDC,,,facility,both,3.25,ML,,42.5,31.88,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641921710,NDC,,,facility,both,4,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042510,NDC,,,facility,both,8,ML,,32.65,24.49,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,4.6,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,2,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,641601310,NDC,,,facility,both,5,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN,118524,CDM,250,RC,55150042501,NDC,,,facility,both,2,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML SOLN 25 ML VIAL,118525,CDM,250,RC,641921910,NDC,,,facility,both,25,ML,,61.35,46.01,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 40 MG/ML SOLN 2 ML VIAL,118596,CDM,636,RC,J3260,HCPCS,63323030602,NDC,facility,both,2,ML,,13.44,10.08,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SOLR 1 EACH VIAL,1188,CDM,636,RC,J0290,HCPCS,65219002003,NDC,facility,both,500,ME,,17.52,13.14,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SOLR 1 EACH VIAL,1188,CDM,636,RC,J0290,HCPCS,781940895,NDC,facility,both,500,ME,,10.86,8.15,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SOLR 1 EACH VIAL,1188,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,both,500,ME,,11.32,8.49,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SOLR 1 EACH VIAL,1188,CDM,636,RC,J0290,HCPCS,781340895,NDC,facility,both,500,ME,,10.86,8.15,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SOLR 1 EACH VIAL,1188,CDM,636,RC,J0290,HCPCS,25021013720,NDC,facility,both,500,ME,,12.46,9.35,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 15 MG TABS,118981,CDM,250,RC,49884076854,NDC,,,facility,both,0.5,UN,,251.4,188.55,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 15 MG TABS,118981,CDM,250,RC,49884076854,NDC,,,facility,both,1,UN,,480.55,360.41,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 15 MG TABS,118981,CDM,250,RC,31722086831,NDC,,,facility,both,1,UN,,103.85,77.89,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 15 MG TABS,118981,CDM,250,RC,31722086831,NDC,,,facility,both,3,UN,,90.92,68.19,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 15 MG TABS,118981,CDM,250,RC,59148002050,NDC,,,facility,both,0.5,UN,,410.45,307.84,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 15 MG TABS,118981,CDM,250,RC,59148002050,NDC,,,facility,both,1,UN,,798.65,598.99,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 15 MG TABS,118981,CDM,250,RC,31722086831,NDC,,,facility,both,0.5,UN,,57.85,43.39,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 30 MG TABS,118982,CDM,250,RC,59148002150,NDC,,,facility,both,2,UN,,816.55,612.41,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 30 MG TABS,118982,CDM,250,RC,67877063633,NDC,,,facility,both,0.25,UN,,130.35,97.76,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 30 MG TABS,118982,CDM,250,RC,59148002150,NDC,,,facility,both,1,UN,,827.65,620.74,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 30 MG TABS,118982,CDM,250,RC,67877063633,NDC,,,facility,both,1,UN,,455.7,341.78,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TB24,119022,CDM,250,RC,16714062501,NDC,,,facility,both,2,UN,,13.82,10.37,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TB24,119022,CDM,250,RC,16714062501,NDC,,,facility,both,1,UN,,18.4,13.8,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 200 MG TB24,119023,CDM,250,RC,228145303,NDC,,,facility,both,1,UN,,27.9,20.92,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 200 MG TB24,119023,CDM,250,RC,228145303,NDC,,,facility,both,2,UN,,22.75,17.06,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 10 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,70700018623,NDC,facility,both,500,ME,,16.03,12.02,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 10 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,both,500,ME,,6.27,4.7,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 100 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,25021021599,NDC,facility,both,500,ME,,9.65,7.24,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 100 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,63323011769,NDC,facility,both,500,ME,,6.38,4.79,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 100 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,62332077931,NDC,facility,both,500,ME,,21.81,16.35,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 100 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,63323011761,NDC,facility,both,500,ME,,6.49,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 100 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,16729027638,NDC,facility,both,500,ME,,20.8,15.6,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 100 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,70700018922,NDC,facility,both,500,ME,,19.36,14.52,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 20 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,63323011720,NDC,facility,both,500,ME,,6.66,5,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 50 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,70700018822,NDC,facility,both,500,ME,,19.17,14.37,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 50 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,62332075150,NDC,facility,both,500,ME,,18.93,14.2,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 50 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,25021021598,NDC,facility,both,500,ME,,6.92,5.19,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 50 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,63323011751,NDC,facility,both,500,ME,,6.76,5.07,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 50 MG/ML SOLN 50 ML VIAL,119299,CDM,636,RC,J9190,HCPCS,16729027611,NDC,facility,both,500,ME,,22.3,16.72,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 100MG/10ML SOLR,11954,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,both,50,ME,,34.04,25.53,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 100MG/10ML SOLR,11954,CDM,636,RC,J0640,HCPCS,143955401,NDC,facility,both,50,ME,,59.26,44.45,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 100MG/10ML SOLR 1 EACH VIAL,11954,CDM,636,RC,J0640,HCPCS,71288016120,NDC,facility,both,50,ME,,20.06,15.04,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 100MG/10ML SOLR 1 EACH VIAL,11954,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,both,50,ME,,8.78,6.58,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 100MG/10ML SOLR 1 EACH VIAL,11954,CDM,636,RC,J0640,HCPCS,67457052810,NDC,facility,both,50,ME,,25.46,19.09,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR,11954,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,both,50,ME,,37,27.75,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR,11954,CDM,636,RC,J0640,HCPCS,143955401,NDC,facility,both,50,ME,,53.55,40.16,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,11954,CDM,636,RC,J0640,HCPCS,67457052810,NDC,facility,both,50,ME,,25.38,19.03,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,11954,CDM,636,RC,J0640,HCPCS,143955401,NDC,facility,both,50,ME,,20.28,15.21,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,11954,CDM,636,RC,J0640,HCPCS,25021081430,NDC,facility,both,50,ME,,15.76,11.82,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 350MG/17.5ML SOLR 1 EACH VIAL,11955,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,both,50,ME,,8.21,6.16,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,11955,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,both,50,ME,,8.05,6.04,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,11955,CDM,636,RC,J0640,HCPCS,67457053035,NDC,facility,both,50,ME,,12.87,9.65,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 50MG/5ML SOLR 1 EACH VIAL,11956,CDM,636,RC,J0640,HCPCS,143955501,NDC,facility,both,50,ME,,20.5,15.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,11956,CDM,636,RC,J0640,HCPCS,143955501,NDC,facility,both,50,ME,,20.5,15.38,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 30 MG/ML SOLN 17 ML VIAL,119720,CDM,636,RC,Q0138,HCPCS,59338077501,NDC,facility,both,1,ME,,1.74,1.31,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 30 MG/ML SOLN 17 ML VIAL,119720,CDM,636,RC,Q0138,HCPCS,781315401,NDC,facility,both,1,ME,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 30 MG/ML SOLN 17 ML VIAL,119720,CDM,636,RC,Q0139,HCPCS,781315401,NDC,facility,both,1,ME,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 30 MG/ML SOLN 17 ML VIAL,119720,CDM,636,RC,Q0139,HCPCS,59338077501,NDC,facility,both,1,ME,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
DRONEDARONE 400 MG TABS,119737,CDM,250,RC,24414260,NDC,,,facility,both,0.5,UN,,19.2,14.4,,,,,,,,,,Gross Charge Type: Pharmacy
DRONEDARONE 400 MG TABS,119737,CDM,250,RC,24414260,NDC,,,facility,both,1,UN,,29.1,21.82,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 10 MG TABS,119781,CDM,250,RC,60505464303,NDC,,,facility,both,0.5,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 10 MG TABS,119781,CDM,250,RC,60505464303,NDC,,,facility,both,1,UN,,9.45,7.09,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 10 MG TABS,119781,CDM,250,RC,60505464303,NDC,,,facility,both,6,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,7,UN,,2.01,1.51,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,2.5,UN,,2.53,1.9,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,1,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,4,UN,,2.12,1.59,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,1.5,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,1.5,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,4.48,UN,,1.72,1.29,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,3,UN,,2.57,1.93,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,4,UN,,2.86,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,1,UN,,5.69,4.27,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,6,UN,,2.2,1.65,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,5,UN,,2.47,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,0.5,UN,,5.8,4.35,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,5,UN,,1.75,1.31,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,2,UN,,4.75,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,0.5,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,2.5,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,51079044420,NDC,,,facility,both,3,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,9,UN,,1.07,0.8,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG TABS,11998,CDM,250,RC,16729044717,NDC,,,facility,both,2,UN,,3.37,2.52,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,2.5,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,74455211,NDC,,,facility,both,1,UN,,10.65,7.99,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,378180377,NDC,,,facility,both,2,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,0.75,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,1,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,2,UN,,4.9,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,378180377,NDC,,,facility,both,0.5,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,2.74,UN,,3.53,2.65,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,378180377,NDC,,,facility,both,1,UN,,8.07,6.05,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,1.5,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,3,UN,,3.62,2.71,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,3.5,UN,,2.84,2.13,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 50 MCG TABS,11999,CDM,250,RC,51079044020,NDC,,,facility,both,4,UN,,2.96,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,1.6667,UN,,4.82,3.62,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,1,UN,,8.69,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,2,UN,,5,3.75,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,0.6667,UN,,2.35,1.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,2.6667,UN,,3.62,2.71,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,1.5,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,1.333333333,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,2.3333,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,3,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,0.5,UN,,7.58,5.69,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,74518211,NDC,,,facility,both,2,UN,,6.82,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,0.3333,UN,,1.2,0.9,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,1.3333,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,51079044120,NDC,,,facility,both,2.666666667,UN,,3.62,2.71,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 75 MCG TABS,12000,CDM,250,RC,74518211,NDC,,,facility,both,1,UN,,10.75,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,0.75,UN,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,2,UN,,5.08,3.81,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,1.75,UN,,4.9,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,0.5,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,1.25,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,74662411,NDC,,,facility,both,1.5,UN,,6.12,4.59,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,3,UN,,3.77,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,74662411,NDC,,,facility,both,1,UN,,9.57,7.17,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,1,UN,,8.43,6.32,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,1.5,UN,,4.75,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,0.25,UN,,0.9,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,74662411,NDC,,,facility,both,3,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG TABS,12001,CDM,250,RC,51079044220,NDC,,,facility,both,0.875,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,2,UN,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,1.5,UN,,4.92,3.69,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,0.5,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,0.8,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,1.2,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,0.48,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,0.7,UN,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,1.4,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,74706811,NDC,,,facility,both,1,UN,,10.75,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,74706811,NDC,,,facility,both,2,UN,,6.82,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,1,UN,,9.02,6.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG TABS,12002,CDM,250,RC,51079044320,NDC,,,facility,both,0.296,UN,,1.25,0.94,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG TABS,12003,CDM,250,RC,51079044520,NDC,,,facility,both,0.75,UN,,1.25,0.94,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG TABS,12003,CDM,250,RC,51079044520,NDC,,,facility,both,1.1667,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG TABS,12003,CDM,250,RC,51079044520,NDC,,,facility,both,0.5,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG TABS,12003,CDM,250,RC,74706911,NDC,,,facility,both,1,UN,,10.75,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG TABS,12003,CDM,250,RC,51079044520,NDC,,,facility,both,0.8333,UN,,2.86,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG TABS,12003,CDM,250,RC,51079044520,NDC,,,facility,both,0.3333,UN,,1.45,1.09,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG TABS,12003,CDM,250,RC,51079044520,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG TABS,12003,CDM,250,RC,51079044520,NDC,,,facility,both,2,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG TABS,12004,CDM,250,RC,74714811,NDC,,,facility,both,1,UN,,10.75,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG TABS,12004,CDM,250,RC,74714811,NDC,,,facility,both,0.56,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG TABS,12004,CDM,250,RC,74714811,NDC,,,facility,both,0.44,UN,,9,6.75,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG TABS,12004,CDM,250,RC,74714811,NDC,,,facility,both,0.625,UN,,9.6,7.2,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG TABS,12004,CDM,250,RC,74714811,NDC,,,facility,both,0.75,UN,,10,7.5,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 1.5 MG TABS,120289,CDM,250,RC,536114263,NDC,,,facility,both,1,UN,,22,16.5,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 1.5 MG TABS,120289,CDM,250,RC,16714080901,NDC,,,facility,both,1,UN,,39.65,29.74,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 1.5 MG TABS,120289,CDM,250,RC,62756072060,NDC,,,facility,both,1,UN,,42.1,31.58,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 5 MG/ML SOLN 10 ML VIAL,120433,CDM,636,RC,J9263,HCPCS,703398501,NDC,facility,both,0.5,ME,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 5 MG/ML SOLN 10 ML VIAL,120433,CDM,636,RC,J9263,HCPCS,781331570,NDC,facility,both,0.5,ME,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 5 MG/ML SOLN 20 ML VIAL,120433,CDM,636,RC,J9263,HCPCS,781331780,NDC,facility,both,0.5,ME,,0.38,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 5 MG/ML SOLN 20 ML VIAL,120433,CDM,636,RC,J9263,HCPCS,703398601,NDC,facility,both,0.5,ME,,1.21,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 5 MG/ML SOLN 20 ML VIAL,120433,CDM,636,RC,J9263,HCPCS,16729033205,NDC,facility,both,0.5,ME,,0.94,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 5 MG/ML SOLN 20 ML VIAL,120433,CDM,636,RC,J9263,HCPCS,71288010120,NDC,facility,both,0.5,ME,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 5 MG/ML SOLN 20 ML VIAL,120433,CDM,636,RC,J9263,HCPCS,25021023320,NDC,facility,both,0.5,ME,,0.75,0.57,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 2.4 G PACK,120509,CDM,250,RC,MHS1EA,HCPCS,65862093190,NDC,facility,both,1,EA,,9.79,7.34,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 2.4 G PACK,120509,CDM,250,RC,MHS1EA,HCPCS,955105490,NDC,facility,both,1,EA,,16.88,12.66,,,,,,,,,,Gross Charge Type: Pharmacy
ASENAPINE 5 MG SUBL,120564,CDM,250,RC,456240563,NDC,,,facility,both,1,UN,,42.1,31.58,,,,,,,,,,Gross Charge Type: Pharmacy
ASENAPINE 5 MG SUBL,120564,CDM,250,RC,456240563,NDC,,,facility,both,2,UN,,36.8,27.6,,,,,,,,,,Gross Charge Type: Pharmacy
ASENAPINE 10 MG SUBL,120565,CDM,250,RC,456241060,NDC,,,facility,both,0.5,UN,,26.1,19.58,,,,,,,,,,Gross Charge Type: Pharmacy
ASENAPINE 10 MG SUBL,120565,CDM,250,RC,456241060,NDC,,,facility,both,2,UN,,36.8,27.6,,,,,,,,,,Gross Charge Type: Pharmacy
ASENAPINE 10 MG SUBL,120565,CDM,250,RC,456241006,NDC,,,facility,both,0.5,UN,,10.15,7.61,,,,,,,,,,Gross Charge Type: Pharmacy
ASENAPINE 10 MG SUBL,120565,CDM,250,RC,456241006,NDC,,,facility,both,1,UN,,12.5,9.38,,,,,,,,,,Gross Charge Type: Pharmacy
ASENAPINE 10 MG SUBL,120565,CDM,250,RC,456241006,NDC,,,facility,both,1.5,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
ASENAPINE 10 MG SUBL,120565,CDM,250,RC,456241060,NDC,,,facility,both,1,UN,,42.1,31.58,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % SOLN,12076,CDM,250,RC,MHS1ML,HCPCS,54350547,NDC,facility,both,1,ML,,2.09,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % SOLN,12076,CDM,250,RC,MHS1ML,HCPCS,70954051810,NDC,facility,both,1,ML,,10.2,7.65,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,MHS1ML,HCPCS,143957710,NDC,facility,both,1,ME,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,FAMRXNC,HCPCS,63323048527,NDC,facility,both,1,ME,,2.03,1.52,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,FAMRXNC,HCPCS,63323020110,NDC,facility,both,1,ME,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,MHS1ML,HCPCS,63323048527,NDC,facility,both,1,ME,,1.61,1.21,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,FAMRXNC,HCPCS,409427601,NDC,facility,both,1,ME,,1.12,0.84,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,J3490,HCPCS,143957710,NDC,facility,both,1,ME,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,J2001,HCPCS,143957710,NDC,facility,both,1,ME,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,FAMRXNC,HCPCS,63323020102,NDC,facility,both,1,ME,,26.75,20.06,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,MHS1ML,HCPCS,55150025220,NDC,facility,both,1,ME,,1.46,1.09,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,J3490,HCPCS,409427601,NDC,facility,both,1,ME,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,MHS1ML,HCPCS,63323020110,NDC,facility,both,1,ME,,3.66,2.75,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,FAMRXNC,HCPCS,143957710,NDC,facility,both,1,ME,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,MHS1ML,HCPCS,409427601,NDC,facility,both,1,ME,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN,12078,CDM,250,RC,FAMRXNC,HCPCS,55150025220,NDC,facility,both,1,ME,,25.2,18.9,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % SOLN,12080,CDM,250,RC,MHS1ML,HCPCS,63323048627,NDC,facility,both,1,ME,,2.67,2,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % SOLN,12080,CDM,250,RC,MHS1ML,HCPCS,55150025520,NDC,facility,both,1,ME,,1.57,1.18,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % SOLN,12080,CDM,250,RC,MHS1ML,HCPCS,409427701,NDC,facility,both,1,ME,,2.56,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % SOLN,12080,CDM,250,RC,FAMRXNC,HCPCS,409427701,NDC,facility,both,1,ME,,1.64,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Med-Surg Semi Private,1210000001,CDM,121,RC,,,,,facility,both,,,,1811,1358.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Room Telemetry Med-Surg Semi Private,1210000002,CDM,121,RC,,,,,facility,both,,,,2256,1692,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
MAGNESIUM HYDROXIDE 10 ML SUSP,121120,CDM,250,RC,MHS10ML,HCPCS,121094010,NDC,facility,both,10,ML,,10.26,7.7,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 10 ML SUSP,121120,CDM,250,RC,MHS10ML,HCPCS,121052710,NDC,facility,both,10,ML,,9.95,7.46,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 10 ML SUSP 10 ML CUP,121120,CDM,250,RC,MHS10ML,HCPCS,121052710,NDC,facility,both,10,ML,,4.87,3.65,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TB24,121194,CDM,250,RC,228285011,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TB24,121194,CDM,250,RC,60505392701,NDC,,,facility,both,2,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TB24,121194,CDM,250,RC,60505392701,NDC,,,facility,both,3,UN,,3.37,2.52,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TB24,121194,CDM,250,RC,60505392701,NDC,,,facility,both,4,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TB24,121194,CDM,250,RC,60505392701,NDC,,,facility,both,1,UN,,8.33,6.25,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 2 MG TB24,121195,CDM,250,RC,60505392801,NDC,,,facility,both,0.5,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 2 MG TB24,121195,CDM,250,RC,60505392801,NDC,,,facility,both,1.5,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 2 MG TB24,121195,CDM,250,RC,60505392801,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 2 MG TB24,121195,CDM,250,RC,60505392801,NDC,,,facility,both,1,UN,,6.16,4.62,,,,,,,,,,Gross Charge Type: Pharmacy
L-METHYLFOLATE 15 MG TABS,121250,CDM,250,RC,51991080990,NDC,,,facility,both,1,UN,,11.95,8.96,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 1.5 MG TB24,121356,CDM,250,RC,43975034903,NDC,,,facility,both,4,UN,,21.84,16.38,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 1.5 MG TB24,121356,CDM,250,RC,43975034903,NDC,,,facility,both,3,UN,,22.78,17.09,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 1.5 MG TB24,121356,CDM,250,RC,43975034903,NDC,,,facility,both,2,UN,,24.55,18.41,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 1.5 MG TB24,121356,CDM,250,RC,43975034903,NDC,,,facility,both,1,UN,,29.8,22.35,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS SOLR,121544,CDM,636,RC,J0586,HCPCS,15054050001,NDC,facility,both,5,UN,,17.18,12.89,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG TABS,12176,CDM,250,RC,59762120701,NDC,,,facility,both,0.5,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG TABS,12176,CDM,250,RC,59762120701,NDC,,,facility,both,3,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG TABS,12176,CDM,250,RC,59762120701,NDC,,,facility,both,1,UN,,9.6,7.2,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG TABS,12176,CDM,250,RC,59762120701,NDC,,,facility,both,0.8,UN,,9.2,6.9,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Obstetrics Semi-Priv,1220000001,CDM,122,RC,,,,,facility,both,,,,1848,1386,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"ERGOCALCIFEROL 1.25 MG (50,000 UNITS) CAPS",122347,CDM,250,RC,64380073706,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 200 UNITS SOLR,122363,CDM,636,RC,J0585,HCPCS,23392102,NDC,facility,both,1,UN,,2208.1,1656.08,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,904679961,NDC,,,facility,both,1.5,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,904679961,NDC,,,facility,both,0.5,UN,,5.89,4.41,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,68180098101,NDC,,,facility,both,1.5,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,68180098101,NDC,,,facility,both,1,UN,,5.17,3.88,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,60687033301,NDC,,,facility,both,0.5,UN,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,60687033301,NDC,,,facility,both,1,UN,,6.34,4.75,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,904679961,NDC,,,facility,both,0.25,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,60687033301,NDC,,,facility,both,2,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,68180098101,NDC,,,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,43547035410,NDC,,,facility,both,2,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,43547035410,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,904679961,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,904679961,NDC,,,facility,both,3,UN,,2.43,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,904679961,NDC,,,facility,both,1,UN,,5.98,4.49,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,68180098101,NDC,,,facility,both,3,UN,,2.43,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG TABS,12248,CDM,250,RC,60687033301,NDC,,,facility,both,3,UN,,2.73,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG CAPS,12258,CDM,250,RC,54852725,NDC,,,facility,both,2,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG CAPS,12258,CDM,250,RC,54852725,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG CAPS,12258,CDM,250,RC,54852725,NDC,,,facility,both,4,UN,,2.1,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG CAPS,12258,CDM,250,RC,54852725,NDC,,,facility,both,3,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TABS,12260,CDM,250,RC,54852825,NDC,,,facility,both,3,UN,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TABS,12260,CDM,250,RC,54852825,NDC,,,facility,both,0.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TABS,12260,CDM,250,RC,54852825,NDC,,,facility,both,4,UN,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TABS,12260,CDM,250,RC,54852825,NDC,,,facility,both,1.5,UN,,3.98,2.98,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TABS,12260,CDM,250,RC,54852825,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TABS,12260,CDM,250,RC,54852825,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
IBUTILIDE 0.1 MG/ML SOLN,122681,CDM,636,RC,J1742,HCPCS,9379401,NDC,facility,both,1,ME,,257.45,193.09,,,,,,,,,,Gross Charge Type: Pharmacy
IBUTILIDE 0.1 MG/ML SOLN 10 ML VIAL,122681,CDM,636,RC,J1742,HCPCS,9379401,NDC,facility,both,1,ME,,257.45,193.09,,,,,,,,,,Gross Charge Type: Pharmacy
DALFAMPRIDINE 10 MG TB12,122896,CDM,250,RC,42571027560,NDC,,,facility,both,1,UN,,12.85,9.64,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Pediatrics Semi Private,1230000001,CDM,123,RC,,,,,facility,both,,,,2329,1746.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
BARIUM SULFATE 700 MG TABS,123048,CDM,250,RC,10361077831,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
COLLAGENASE CLOSTRID HISTOLYT 0.9 MG IJ SOLR,123065,CDM,66887000301,NDC,,,,,facility,both,0.01,EA,,153.54,115.16,,,,,,,,,,Gross Charge Type: Pharmacy
COLLAGENASE HYSTOLYTICUM COLLAGENASE 0.9 MG SOLR,123065,CDM,636,RC,J0775,HCPCS,66887000301,NDC,facility,both,0.01,ME,,152.26,114.19,,,,,,,,,,Gross Charge Type: Pharmacy
MENINGOCOCCAL CONJUGATE VACCINE SOLR,123086,CDM,636,RC,90734,HCPCS,58160095509,NDC,facility,both,0.5,ML,,231.18,173.39,,,,,,,,,,Gross Charge Type: Pharmacy
ICODEXTRIN (EXTRANEAL) 7.5% PERITONEAL DIALYSIS SOLUTION 7.5 % SOLN,123259,CDM,250,RC,941067952,NDC,,,facility,both,800,ML,,14.75,11.06,,,,,,,,,,Gross Charge Type: Pharmacy
ICODEXTRIN (EXTRANEAL) 7.5% PERITONEAL DIALYSIS SOLUTION 7.5 % SOLN,123259,CDM,250,RC,941067952,NDC,,,facility,both,1400,ML,,24.9,18.68,,,,,,,,,,Gross Charge Type: Pharmacy
ICODEXTRIN (EXTRANEAL) 7.5% PERITONEAL DIALYSIS SOLUTION 7.5 % SOLN,123259,CDM,250,RC,941067952,NDC,,,facility,both,2000,ML,,25.35,19.01,,,,,,,,,,Gross Charge Type: Pharmacy
ICODEXTRIN (EXTRANEAL) 7.5% PERITONEAL DIALYSIS SOLUTION 7.5 % SOLN,123259,CDM,250,RC,941067952,NDC,,,facility,both,1500,ML,,26.2,19.65,,,,,,,,,,Gross Charge Type: Pharmacy
"ICODEXTRIN (EXTRANEAL) 7.5% PERITONEAL DIALYSIS SOLUTION 7.5 % SOLN 2,000 ML FLEX CONT",123259,CDM,250,RC,941067952,NDC,,,facility,both,2000,ML,,25.35,19.01,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,50268074015,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,68084029901,NDC,,,facility,both,2,UN,,5.12,3.84,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,68382013201,NDC,,,facility,both,1,UN,,7.64,5.73,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,63739056710,NDC,,,facility,both,1,UN,,7.84,5.88,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,63739056710,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,72603011501,NDC,,,facility,both,2,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,50268074015,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,68382013201,NDC,,,facility,both,2,UN,,4.42,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,65862059801,NDC,,,facility,both,1,UN,,6.77,5.08,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,72603011501,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,65862059801,NDC,,,facility,both,2,UN,,3.78,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,123275,CDM,250,RC,68084029901,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,55150016330,NDC,facility,both,1,ME,,1.24,0.93,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,J3490,HCPCS,55150016205,NDC,facility,both,1,ME,,5.48,4.11,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,J3490,HCPCS,409427902,NDC,facility,both,1,ME,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,FAMRXNC,HCPCS,63323049231,NDC,facility,both,1,ME,,0.44,0.33,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,FAMRXNC,HCPCS,55150016205,NDC,facility,both,1,ME,,2.73,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,409471332,NDC,facility,both,1,ME,,9.29,6.96,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,72572037001,NDC,facility,both,1,ME,,6.71,5.03,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,55150016205,NDC,facility,both,1,ME,,9.06,6.8,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,63323049237,NDC,facility,both,1,ME,,2.71,2.03,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,FAMRXNC,HCPCS,409427902,NDC,facility,both,1,ME,,1.23,0.92,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,6937498505,NDC,facility,both,1,ME,,8.19,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,FAMRXNC,HCPCS,55150016330,NDC,facility,both,1,ME,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,73293000102,NDC,facility,both,1,ME,,25.45,19.09,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,FAMRXNC,HCPCS,63323049237,NDC,facility,both,1,ME,,3.29,2.47,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,409427902,NDC,facility,both,1,ME,,1.18,0.88,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,63323049257,NDC,facility,both,1,ME,,25.75,19.31,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN,123592,CDM,250,RC,MHS1ML,HCPCS,65857045005,NDC,facility,both,1,ME,,7.74,5.8,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN 2 ML AMPULE,123592,CDM,250,RC,MHS1ML,HCPCS,409471332,NDC,facility,both,1,ME,,10.8,8.1,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN 30 ML VIAL,123592,CDM,250,RC,MHS1ML,HCPCS,409427902,NDC,facility,both,1,ME,,1.23,0.92,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN 5 ML SYRINGE,123592,CDM,250,RC,MHS1ML,HCPCS,6937498505,NDC,facility,both,1,ME,,11.1,8.32,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN 5 ML VIAL,123592,CDM,250,RC,MHS1ML,HCPCS,73293000102,NDC,facility,both,1,ME,,9.97,7.47,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN 5 ML VIAL,123592,CDM,250,RC,MHS1ML,HCPCS,55150016205,NDC,facility,both,1,ME,,9.19,6.89,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1 % (PF) SOLN 5 ML VIAL,123592,CDM,250,RC,MHS1ML,HCPCS,72572037001,NDC,facility,both,1,ME,,6.74,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 2 % (PF) SOLN,123593,CDM,250,RC,72572037201,NDC,,,facility,both,1,ME,,170.15,127.61,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 2 % (PF) SOLN,123593,CDM,250,RC,143959425,NDC,,,facility,both,1,ME,,31.8,23.85,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 2 % (PF) SOLN,123593,CDM,250,RC,72572037225,NDC,,,facility,both,1,ME,,32.75,24.56,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 2 % (PF) SOLN,123593,CDM,250,RC,409428202,NDC,,,facility,both,1,ME,,20.93,15.7,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 2 % (PF) SOLN,123593,CDM,250,RC,63323049507,NDC,,,facility,both,1,ME,,27.6,20.7,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 2 % (PF) SOLN,123593,CDM,250,RC,409206605,NDC,,,facility,both,1,ME,,29.34,22,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 2 % (PF) SOLN,123593,CDM,250,RC,J3490,HCPCS,143959425,NDC,facility,both,1,ME,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 2 % (PF) SOLN,123593,CDM,250,RC,55150016505,NDC,,,facility,both,1,ME,,33.35,25.01,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 2 % (PF) SOLN,123593,CDM,250,RC,FAMRXNC,HCPCS,63323049527,NDC,facility,both,1,ME,,19.25,14.44,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG CAPS,12371,CDM,250,RC,60687022901,NDC,,,facility,both,1,UN,,8.99,6.74,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG CAPS,12371,CDM,250,RC,60687022901,NDC,,,facility,both,4,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG CAPS,12371,CDM,250,RC,60687022901,NDC,,,facility,both,2,UN,,5.18,3.88,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 0.15 % GEL 5 G TUBE,123918,CDM,250,RC,24208053535,NDC,,,facility,both,5,GR,,620.7,465.52,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML CONC,12392,CDM,250,RC,MHS1ML,HCPCS,54353244,NDC,facility,both,1,ML,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,904600761,NDC,,,facility,both,1.5,UN,,2.68,2.01,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,904600761,NDC,,,facility,both,4,UN,,1.41,1.06,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,69315090401,NDC,,,facility,both,3,UN,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,904600761,NDC,,,facility,both,2,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,69315090401,NDC,,,facility,both,1,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,904600761,NDC,,,facility,both,1,UN,,5.29,3.97,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,904600761,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,904600761,NDC,,,facility,both,3,UN,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,69315090401,NDC,,,facility,both,2,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,904600761,NDC,,,facility,both,6,UN,,0.98,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG TABS,12393,CDM,250,RC,69315090401,NDC,,,facility,both,4,UN,,1.45,1.09,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008401,NDC,,,facility,both,3,UN,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008401,NDC,,,facility,both,1,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008405,NDC,,,facility,both,1,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008405,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008401,NDC,,,facility,both,4,UN,,1.48,1.11,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,904600861,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,904600861,NDC,,,facility,both,3,UN,,1.87,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,69315090501,NDC,,,facility,both,1,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,93342601,NDC,,,facility,both,1,UN,,5.16,3.87,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,93342601,NDC,,,facility,both,3,UN,,1.8,1.35,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008401,NDC,,,facility,both,1.5,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008405,NDC,,,facility,both,2,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,93342601,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,904600861,NDC,,,facility,both,2,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008405,NDC,,,facility,both,4,UN,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,93342601,NDC,,,facility,both,4,UN,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,591024101,NDC,,,facility,both,1,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,904600861,NDC,,,facility,both,1,UN,,5.26,3.95,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008401,NDC,,,facility,both,2,UN,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,13107008401,NDC,,,facility,both,0.5,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,904600861,NDC,,,facility,both,4,UN,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,904600861,NDC,,,facility,both,1.5,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,93342601,NDC,,,facility,both,2,UN,,2.65,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,69315090501,NDC,,,facility,both,0.5,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,69315090501,NDC,,,facility,both,4,UN,,1.48,1.11,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,12394,CDM,250,RC,69315090501,NDC,,,facility,both,2,UN,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG TABS,123946,CDM,250,RC,65649030303,NDC,,,facility,both,1,UN,,92.62,69.46,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG TABS,12395,CDM,250,RC,69315090601,NDC,,,facility,both,1,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG TABS,12395,CDM,250,RC,69315090601,NDC,,,facility,both,2,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG TABS,12395,CDM,250,RC,13107008501,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG TABS,12395,CDM,250,RC,13107008501,NDC,,,facility,both,1,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG TABS,12395,CDM,250,RC,13107008501,NDC,,,facility,both,3,UN,,1.85,1.39,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG TABS,12395,CDM,250,RC,13107008501,NDC,,,facility,both,2,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG TABS,12395,CDM,250,RC,904600961,NDC,,,facility,both,2,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG TABS,12395,CDM,250,RC,904600961,NDC,,,facility,both,1,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Psychiatric-Semi Private,1240000001,CDM,124,RC,,,,,facility,both,,,,2608,1956,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,500,ML,,1.65,1.24,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,5,ML,,26.99,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,50,ML,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,40,ML,,8.24,6.18,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,4,ML,,26.88,20.16,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,7,ML,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,70,ML,,5.57,4.18,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,60,ML,,6.16,4.62,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,6,ML,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,10,ML,,26.99,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,1,ML,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,1000,ML,,1.21,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,13,ML,,14.5,10.88,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,30,ML,,10.33,7.75,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,3,ML,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,64253011130,NDC,,,facility,both,20,ML,,34.98,26.23,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,20,ML,,14.5,10.87,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,2,ML,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,26,ML,,10.33,7.75,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,32,ML,,8.25,6.19,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,64253011130,NDC,,,facility,both,10,ML,,53.1,39.82,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306553,NDC,,,facility,both,30,ML,,12.5,9.38,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306553,NDC,,,facility,both,10,ML,,29.2,21.9,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,8,ML,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,80,ML,,5.12,3.84,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,160,ML,,3.56,2.67,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,16,ML,,14.5,10.88,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,15,ML,,14.5,10.87,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,1.5,ML,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306553,NDC,,,facility,both,20,ML,,16.68,12.51,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN,124021,CDM,250,RC,8290306547,NDC,,,facility,both,25,ML,,10.33,7.75,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (NS) 0.9% NACL SOLN 125 ML SYRINGE,124021,CDM,250,RC,19118827,NDC,,,facility,both,4.5,ML,,27.7,20.78,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 0.5 MG TABS,124091,CDM,636,RC,J7520,HCPCS,68382052001,NDC,facility,both,1,ME,,25.64,19.23,,,,,,,,,,Gross Charge Type: Pharmacy
EVEROLIMUS 0.5 MG TABS,124376,CDM,636,RC,54047121,NDC,,,facility,both,3,UN,,103.78,77.84,,,,,,,,,,Gross Charge Type: Pharmacy
LUBRIDERM UNSCENTED LOTION LOTN 473 ML BOTTLE,12485,CDM,250,RC,MHS1ML,HCPCS,52800048856,NDC,facility,both,1,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL SOLN 60 MG VIAL,125149,CDM,636,RC,J9043,HCPCS,24582411,NDC,facility,both,1,ME,,586.98,440.23,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/ML SOLN,125543,CDM,636,RC,J1650,HCPCS,548560800,NDC,facility,both,10,ME,,12.62,9.46,,,,,,,,,,Gross Charge Type: Pharmacy
INCOBOTULINUMTOXINA 50 UNITS IM SOLR,125562,CDM,259160501,NDC,,,,,facility,both,1,EA,,16.49,12.37,,,,,,,,,,Gross Charge Type: Pharmacy
INCOBOTULINUMTOXINA 50 UNITS SOLR,125562,CDM,636,RC,J0588,HCPCS,259160501,NDC,facility,both,1,UN,,16.46,12.35,,,,,,,,,,Gross Charge Type: Pharmacy
BIMATOPROST 0.01 % SOLN 2.5 ML BOTTLE,125909,CDM,250,RC,23320503,NDC,,,facility,both,2.5,ML,,355.7,266.78,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25% W/EPI  PRESERVATIVE FREE 0.25 % (PF) SOLN,125927,CDM,250,RC,MHS10ML,HCPCS,409904201,NDC,facility,both,10,ML,,40.22,30.16,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25% W/EPI  PRESERVATIVE FREE 0.25 % (PF) SOLN,125927,CDM,250,RC,MHS10ML,HCPCS,63323046837,NDC,facility,both,10,ML,,24.43,18.32,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25% W/EPI  PRESERVATIVE FREE 0.25 % (PF) SOLN,125927,CDM,250,RC,MHS10ML,HCPCS,63323046817,NDC,facility,both,10,ML,,44.98,33.74,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25% W/EPI  PRESERVATIVE FREE 0.25 % (PF) SOLN,125927,CDM,250,RC,MHS10ML,HCPCS,409174630,NDC,facility,both,10,ML,,20.49,15.37,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25% W/EPI  PRESERVATIVE FREE 0.25 % (PF) SOLN,125927,CDM,250,RC,MHS10ML,HCPCS,409174610,NDC,facility,both,10,ML,,49.25,36.94,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPI PRESERVATIVE FREE 0.5 % (PF) SOLN,125928,CDM,250,RC,MHS1ML,HCPCS,409904501,NDC,facility,both,1,ML,,3.87,2.9,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPI PRESERVATIVE FREE 0.5 % (PF) SOLN,125928,CDM,250,RC,MHS1ML,HCPCS,63323046217,NDC,facility,both,1,ML,,6.51,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPI PRESERVATIVE FREE 0.5 % (PF) SOLN,125928,CDM,250,RC,MHS1ML,HCPCS,63323046201,NDC,facility,both,1,ML,,3.74,2.8,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPI PRESERVATIVE FREE 0.5 % (PF) SOLN,125928,CDM,250,RC,FAMRXNC,HCPCS,63323046201,NDC,facility,both,1,ML,,0.62,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPI PRESERVATIVE FREE 0.5 % (PF) SOLN,125928,CDM,250,RC,MHS1ML,HCPCS,409904517,NDC,facility,both,1,ML,,1.4,1.05,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPI PRESERVATIVE FREE 0.5 % (PF) SOLN,125928,CDM,250,RC,MHS1ML,HCPCS,409174929,NDC,facility,both,1,ML,,1.93,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,125932,CDM,55150016830,NDC,,,,,facility,both,0.5,ML,,5.11,3.83,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,125932,CDM,409115902,NDC,,,,,facility,both,0.5,ML,,0.23,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,MHS10ML,HCPCS,409115901,NDC,facility,both,0.5,ME,,14.03,10.52,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,636,RC,FAMRXNC,HCPCS,55150016830,NDC,facility,both,0.5,ME,,21.92,16.44,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,636,RC,J0665,HCPCS,55150016830,NDC,facility,both,0.5,ME,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,636,RC,FAMRXNC,HCPCS,409115902,NDC,facility,both,0.5,ME,,10.61,7.95,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,636,RC,J0665,HCPCS,409115902,NDC,facility,both,0.5,ME,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,FAMRXNC,HCPCS,409115902,NDC,facility,both,0.5,ME,,0.8,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,636,RC,J0665,HCPCS,409115901,NDC,facility,both,0.5,ME,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,J3490,HCPCS,409115902,NDC,facility,both,0.5,ME,,0.8,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,MHS10ML,HCPCS,55150016830,NDC,facility,both,0.5,ME,,21.44,16.08,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,FAMRXNC,HCPCS,55150016830,NDC,facility,both,0.5,ME,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,J3490,HCPCS,55150016830,NDC,facility,both,0.5,ME,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,MHS10ML,HCPCS,409155930,NDC,facility,both,0.5,ME,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,J0665,HCPCS,55150016830,NDC,facility,both,0.5,ME,,0.59,0.44,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,636,RC,J0665,HCPCS,409155918,NDC,facility,both,0.5,ME,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,MHS10ML,HCPCS,409115902,NDC,facility,both,0.5,ME,,0.8,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,636,RC,FAMRXNC,HCPCS,409155918,NDC,facility,both,0.5,ME,,20.66,15.5,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,636,RC,FAMRXNC,HCPCS,409115901,NDC,facility,both,0.5,ME,,32.55,24.41,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.25 % (PF) SOLN,125932,CDM,250,RC,FAMRXNC,HCPCS,409115901,NDC,facility,both,0.5,ME,,32.55,24.41,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,125933,CDM,409116201,NDC,,,,,facility,both,0.5,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,250,RC,J3490,HCPCS,409116202,NDC,facility,both,0.5,ME,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,636,RC,FAMRXNC,HCPCS,55150017030,NDC,facility,both,0.5,ME,,1.4,1.05,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,636,RC,J0665,HCPCS,409156029,NDC,facility,both,0.5,ME,,0.18,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,250,RC,MHS1ML,HCPCS,409116202,NDC,facility,both,0.5,ME,,1.13,0.84,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,636,RC,J0665,HCPCS,409116202,NDC,facility,both,0.5,ME,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,636,RC,J0665,HCPCS,409116210,NDC,facility,both,0.5,ME,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,636,RC,FAMRXNC,HCPCS,409116201,NDC,facility,both,0.5,ME,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,636,RC,J0665,HCPCS,409116201,NDC,facility,both,0.5,ME,,0.91,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,636,RC,FAMRXNC,HCPCS,409116202,NDC,facility,both,0.5,ME,,0.43,0.32,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,250,RC,J0665,HCPCS,409116210,NDC,facility,both,0.5,ME,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,636,RC,J0665,HCPCS,55150017030,NDC,facility,both,0.5,ME,,0.14,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,250,RC,FAMRXNC,HCPCS,409116202,NDC,facility,both,0.5,ME,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,250,RC,J0665,HCPCS,409156029,NDC,facility,both,0.5,ME,,0.18,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,250,RC,MHS1ML,HCPCS,409156029,NDC,facility,both,0.5,ME,,1.77,1.33,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN,125933,CDM,250,RC,MHS1ML,HCPCS,409116210,NDC,facility,both,0.5,ME,,1.13,0.84,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN 30 ML VIAL,125933,CDM,250,RC,MHS1ML,HCPCS,409156029,NDC,facility,both,0.5,ME,,1.77,1.33,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN 30 ML VIAL,125933,CDM,636,RC,J0665,HCPCS,409156029,NDC,facility,both,0.5,ME,,0.18,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE PRESERVATIVE FREE 0.5 % (PF) SOLN 30 ML VIAL,125933,CDM,250,RC,J0665,HCPCS,409156029,NDC,facility,both,0.5,ME,,0.18,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,12496120203,NDC,,,facility,both,1,UN,,10.2,7.65,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,47781035503,NDC,,,facility,both,2,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,47781035503,NDC,,,facility,both,0.5,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,47781035503,NDC,,,facility,both,4,UN,,6.89,5.17,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,47781035503,NDC,,,facility,both,0.25,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,47781035503,NDC,,,facility,both,0.125,UN,,5.9,4.42,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,47781035503,NDC,,,facility,both,3,UN,,7.33,5.5,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,378876593,NDC,,,facility,both,1,UN,,13.6,10.2,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,47781035503,NDC,,,facility,both,1,UN,,10.8,8.1,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG FILM,125963,CDM,250,RC,12496120203,NDC,,,facility,both,2,UN,,12.78,9.58,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,12496120803,NDC,,,facility,both,1,UN,,23.45,17.59,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,12496120803,NDC,,,facility,both,2,UN,,20.52,15.39,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,2,UN,,13.12,9.84,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,12496120803,NDC,,,facility,both,1.5,UN,,16.18,12.13,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,1.5,UN,,10.5,7.88,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,1.75,UN,,11.82,8.87,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,1,UN,,15.75,11.81,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,1.25,UN,,9.18,6.88,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,0.75,UN,,13.1,9.82,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,3,UN,,12.12,9.09,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,12496120803,NDC,,,facility,both,0.5,UN,,14.35,10.76,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,12496120803,NDC,,,facility,both,1.75,UN,,18.35,13.76,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,0.25,UN,,7.85,5.89,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,2.5,UN,,10.45,7.84,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG FILM,125964,CDM,250,RC,47781035703,NDC,,,facility,both,0.5,UN,,10.45,7.84,,,,,,,,,,Gross Charge Type: Pharmacy
"Hc Room Detox, Semi-Priviate",1260000001,CDM,126,RC,,,,,facility,both,,,,2779,2084.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Room Detoxification Semi Private, Two Beds",1260000002,CDM,126,RC,,,,,facility,both,,,,2779,2084.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10000-0.1 SUSP 5 ML BOTTLE,126035,CDM,250,RC,61314063006,NDC,,,facility,both,5,ML,,50.1,37.58,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10,000-0.1 OINT 3.5 G TUBE",126036,CDM,250,RC,61314063136,NDC,,,facility,both,3.5,GR,,54.45,40.84,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10,000-0.1 OINT 3.5 G TUBE",126036,CDM,250,RC,574416035,NDC,,,facility,both,7,GR,,38.1,28.58,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5-10,000-0.1 OINT 3.5 G TUBE",126036,CDM,250,RC,574416035,NDC,,,facility,both,3.5,GR,,51.55,38.66,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 0.5 % SOLN,126137,CDM,250,RC,63323049157,NDC,,,facility,both,1,ME,,73.65,55.24,,,,,,,,,,Gross Charge Type: Pharmacy
DABIGATRAN 150 MG CAPS,126515,CDM,250,RC,597036055,NDC,,,facility,both,1,UN,,20.15,15.11,,,,,,,,,,Gross Charge Type: Pharmacy
DABIGATRAN 150 MG CAPS,126515,CDM,250,RC,597036082,NDC,,,facility,both,1,UN,,20.15,15.11,,,,,,,,,,Gross Charge Type: Pharmacy
DABIGATRAN 75 MG CAPS,126721,CDM,250,RC,597035556,NDC,,,facility,both,2,UN,,15.45,11.59,,,,,,,,,,Gross Charge Type: Pharmacy
DABIGATRAN 75 MG CAPS,126721,CDM,250,RC,597035556,NDC,,,facility,both,1,UN,,20.15,15.11,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT SOLR 1 EACH VIAL,126953,CDM,636,RC,J1453,HCPCS,16714024801,NDC,facility,both,1,ME,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT SOLR 1 EACH VIAL,126953,CDM,636,RC,J1453,HCPCS,143938401,NDC,facility,both,1,ME,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT SOLR 1 EACH VIAL,126953,CDM,636,RC,J1453,HCPCS,6306100,NDC,facility,both,1,ME,,6.74,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML SOLN,126974,CDM,636,RC,J0897,HCPCS,55513073001,NDC,facility,both,1,ME,,59.26,44.44,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE 1.745 GM/30ML SOLN,12711,CDM,250,RC,MHS1EA,HCPCS,71399788901,NDC,facility,both,1,EA,,1.12,0.84,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE 1.745 GM/30ML SOLN,12711,CDM,250,RC,MHS1EA,HCPCS,70677111101,NDC,facility,both,1,EA,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 5 MCG/HR PTWK,127151,CDM,250,RC,59011075004,NDC,,,facility,both,1,UN,,147.92,110.94,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 5 MCG/HR PTWK,127151,CDM,250,RC,59011075004,NDC,,,facility,both,3,UN,,134.27,100.7,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 5 MCG/HR PTWK,127151,CDM,250,RC,59011075004,NDC,,,facility,both,2,UN,,145.39,109.04,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 20 MCG/HR PTWK,127153,CDM,250,RC,59011075204,NDC,,,facility,both,1,UN,,392.05,294.04,,,,,,,,,,Gross Charge Type: Pharmacy
PEGLOTICASE 8 MG/ML SOLN 1 ML VIAL,127155,CDM,636,RC,J2507,HCPCS,75987008010,NDC,facility,both,1,ME,,8339.16,6254.37,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TB12,127156,CDM,250,RC,27241010806,NDC,,,facility,both,2,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TB12,127156,CDM,250,RC,27241010806,NDC,,,facility,both,1,UN,,11.1,8.32,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TB12,127156,CDM,250,RC,27241010806,NDC,,,facility,both,3,UN,,5.73,4.3,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,904735661,NDC,,,facility,both,2,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,63402030430,NDC,,,facility,both,2,UN,,74.95,56.21,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,63402030430,NDC,,,facility,both,4,UN,,69.4,52.05,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,904735661,NDC,,,facility,both,3,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,63402030430,NDC,,,facility,both,1.5,UN,,58.45,43.84,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,63402030430,NDC,,,facility,both,3.5,UN,,61.41,46.06,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,63402030430,NDC,,,facility,both,0.5,UN,,45.19,33.89,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,904735661,NDC,,,facility,both,2.5,UN,,4.18,3.14,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,904735661,NDC,,,facility,both,1,UN,,8.13,6.1,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,63402030430,NDC,,,facility,both,1,UN,,79.87,59.9,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 40 MG TABS,127159,CDM,250,RC,63402030430,NDC,,,facility,both,3,UN,,71.25,53.44,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE 400 MG SOLR 1 EACH VIAL,127161,CDM,636,RC,J0712,HCPCS,456040010,NDC,facility,both,10,ME,,13.23,9.92,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE 600 MG SOLR 1 EACH VIAL,127162,CDM,636,RC,J0712,HCPCS,456060010,NDC,facility,both,10,ME,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-QUINIDINE 20-10 MG CAPS,127163,CDM,250,RC,64597030160,NDC,,,facility,both,1,UN,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 500 MG/ML SOLN,12722,CDM,636,RC,J3475,HCPCS,63323064201,NDC,facility,both,500,ME,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 500 MG/ML SOLN,12722,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,both,500,ME,,12.3,9.22,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 500 MG/ML SOLN,12722,CDM,636,RC,J3475,HCPCS,63323006403,NDC,facility,both,500,ME,,14.32,10.74,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 500 MG/ML SOLN 10 ML VIAL,12722,CDM,636,RC,J3475,HCPCS,63323006404,NDC,facility,both,500,ME,,10.55,7.91,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 500 MG/ML SOLN 2 ML VIAL,12722,CDM,636,RC,J3475,HCPCS,63323006403,NDC,facility,both,500,ME,,15.64,11.73,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 500 MG/ML SOLN 20 ML VIAL,12722,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,both,500,ME,,11.6,8.7,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 5 GM/50 ML (10 %) SOLN,127243,CDM,636,RC,J1569,HCPCS,944270004,NDC,facility,both,500,ME,,125,93.75,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 5 GM/50 ML (10 %) SOLN,127243,CDM,636,RC,J1561,HCPCS,944270007,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 5 GM/50 ML (10 %) SOLN,127243,CDM,636,RC,J1569,HCPCS,944270005,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 10 GM/100 ML (10 %) SOLN,127244,CDM,636,RC,J1569,HCPCS,944270006,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 10 GM/100 ML (10 %) SOLN,127244,CDM,636,RC,J1569,HCPCS,944270005,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 10 GM/100 ML (10 %) SOLN,127244,CDM,636,RC,J1569,HCPCS,944270004,NDC,facility,both,500,ME,,132.08,99.06,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 10 GM/100 ML (10 %) SOLN,127244,CDM,636,RC,J1561,HCPCS,944270007,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 20 G/200 ML (10 %) SOLN,127245,CDM,636,RC,J1569,HCPCS,944270004,NDC,facility,both,500,ME,,132.08,99.06,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 20 G/200 ML (10 %) SOLN,127245,CDM,636,RC,J1569,HCPCS,944270005,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 20 G/200 ML (10 %) SOLN,127245,CDM,636,RC,J1561,HCPCS,944270007,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 20 G/200 ML (10 %) SOLN,127245,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,both,500,ME,,132.8,99.6,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 20 G/200 ML (10 %) SOLN,127245,CDM,636,RC,J1561,HCPCS,13533080071,NDC,facility,both,500,ME,,132.98,99.74,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 20 G/200 ML (10 %) SOLN,127245,CDM,636,RC,J1569,HCPCS,944270006,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 20 G/200 ML (10 %) SOLN 200 ML GLASS CONT,127245,CDM,636,RC,J1569,HCPCS,944270006,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 20 G/200 ML (10 %) SOLN 200 ML VIAL,127245,CDM,636,RC,J1561,HCPCS,13533080024,NDC,facility,both,500,ME,,132.8,99.6,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 20 G/200 ML (10 %) SOLN 400 ML VIAL,127245,CDM,636,RC,J1561,HCPCS,13533080040,NDC,facility,both,500,ME,,132.98,99.74,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 10 MG/ML SOLN,127491,CDM,636,RC,J0137,HCPCS,143938610,NDC,facility,both,10,ME,,0.84,0.63,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 10 MG/ML SOLN,127491,CDM,636,RC,J0131,HCPCS,36000030660,NDC,facility,both,10,ME,,0.74,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 10 MG/ML SOLN,127491,CDM,636,RC,J0134,HCPCS,63323043400,NDC,facility,both,10,ME,,0.66,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 10 MG/ML SOLN,127491,CDM,636,RC,J0131,HCPCS,781315695,NDC,facility,both,10,ME,,1.22,0.92,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 10 MG/ML SOLN,127491,CDM,636,RC,J0131,HCPCS,55150030724,NDC,facility,both,10,ME,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20 % SOLN,12792,CDM,250,RC,MHS100ML,HCPCS,338035702,NDC,facility,both,100,ML,,34.29,25.71,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20 % SOLN,12792,CDM,250,RC,MHS100ML,HCPCS,990771503,NDC,facility,both,100,ML,,18.76,14.07,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20 % SOLN,12792,CDM,250,RC,MHS100ML,HCPCS,990771502,NDC,facility,both,100,ML,,34.52,25.89,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20 % SOLN,12792,CDM,250,RC,MHS100ML,HCPCS,264757810,NDC,facility,both,100,ML,,34.56,25.92,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % SOLN,12793,CDM,636,RC,J2150,HCPCS,409403101,NDC,facility,both,50,ML,,15.17,11.38,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMIN D3 125 MCG (5000 UT) CAPS,127957,CDM,250,RC,50268086815,NDC,,,facility,both,2,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMIN D3 125 MCG (5000 UT) CAPS,127957,CDM,250,RC,50268086815,NDC,,,facility,both,1,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMIN D3 125 MCG (5000 UT) CAPS,127957,CDM,250,RC,80681013100,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4ML SOLN 4 ML VIAL,127989,CDM,636,RC,J9351,HCPCS,409030201,NDC,facility,both,0.1,ME,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Cd Rehab-Semi Private,1280000001,CDM,128,RC,,,,,facility,both,,,,2779,2084.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
FONDAPARINUX 7.5 MG/0.6 ML SOLN,128364,CDM,636,RC,J1652,HCPCS,67457058406,NDC,facility,both,0.5,ME,,13.24,9.93,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE 50 MG/5GM (1%) GEL,128373,CDM,250,RC,591321730,NDC,,,facility,both,7.5,GR,,15.55,11.66,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE 50 MG/5GM (1%) GEL,128373,CDM,250,RC,591321730,NDC,,,facility,both,5,GR,,22.6,16.95,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 20 MG/ML SOLN 20 ML VIAL,128389,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,both,10,ME,,420.98,315.73,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 20 MG/ML SOLN 5 ML VIAL,128389,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,both,10,ME,,452.85,339.64,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 20 MG/ML SOLN 4 ML VIAL,128395,CDM,636,RC,J3262,HCPCS,50242013501,NDC,facility,both,1,ME,,16.75,12.56,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 20 MG/ML SOLN 10 ML VIAL,128397,CDM,636,RC,J3262,HCPCS,50242013601,NDC,facility,both,1,ME,,15.83,11.87,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 20 MG/ML SOLN 20 ML VIAL,128397,CDM,636,RC,J3262,HCPCS,50242013701,NDC,facility,both,1,ME,,16.04,12.03,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 20 MG/ML SOLN 20 ML VIAL,128397,CDM,636,RC,Q0249,HCPCS,50242013701,NDC,facility,both,1,ME,,16.1,12.08,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 20 MG/ML SOLN 4 ML VIAL,128397,CDM,636,RC,J3262,HCPCS,50242013501,NDC,facility,both,1,ME,,16.31,12.23,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML SOLN 4 ML VIAL,128399,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,both,10,ME,,272.2,204.15,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML SOLN 16 ML VIAL,128400,CDM,636,RC,J9035,HCPCS,50242006101,NDC,facility,both,10,ME,,227.51,170.63,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML SOLN 4 ML VIAL,128400,CDM,636,RC,J9035,HCPCS,50242006001,NDC,facility,both,10,ME,,235.41,176.56,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM 300 MCG/0.5ML SOSY,128409,CDM,636,RC,J1442,HCPCS,55513092410,NDC,facility,both,0.75,ML,,2.87,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM 300 MCG/0.5ML SOSY,128409,CDM,636,RC,J1442,HCPCS,55513092491,NDC,facility,both,0.5,ML,,3.39,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM 300 MCG/0.5ML SOSY,128409,CDM,636,RC,J1442,HCPCS,55513092410,NDC,facility,both,0.5,ML,,3.36,2.52,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 5 MG/ML SOLN,128453,CDM,636,RC,J1956,HCPCS,143972124,NDC,facility,both,250,ME,,20.01,15.01,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 5 MG/ML SOLN,128454,CDM,636,RC,J1956,HCPCS,143972024,NDC,facility,both,250,ME,,13.33,10,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 2 MG/ML SOLN,128462,CDM,636,RC,J0744,HCPCS,25021011487,NDC,facility,both,200,ME,,23.28,17.46,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 2 MG/ML SOLN,128462,CDM,636,RC,J0744,HCPCS,25021011482,NDC,facility,both,200,ME,,97.09,72.82,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 250 MG/ML SOLN 2 ML VIAL,128463,CDM,636,RC,J0278,HCPCS,23155029041,NDC,facility,both,100,ME,,6.16,4.62,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 250 MG/ML SOLN 2 ML VIAL,128463,CDM,636,RC,J0278,HCPCS,63323081521,NDC,facility,both,100,ME,,9.71,7.28,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG SOLR 1 EACH VIAL,128683,CDM,636,RC,J0490,HCPCS,49401010101,NDC,facility,both,10,ME,,124.2,93.15,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG SOLR 1 EACH VIAL,128684,CDM,636,RC,J0490,HCPCS,49401010201,NDC,facility,both,10,ME,,122.95,92.21,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 80 MG/8ML SOLN 16 ML VIAL,128748,CDM,636,RC,J9171,HCPCS,67457053316,NDC,facility,both,1,ME,,7.22,5.41,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 80 MG/8ML SOLN 8 ML VIAL,128748,CDM,636,RC,J9171,HCPCS,409020110,NDC,facility,both,1,ME,,11.16,8.37,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 80 MG/8ML SOLN 8 ML VIAL,128748,CDM,636,RC,J9171,HCPCS,71288014408,NDC,facility,both,1,ME,,3.62,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 80 MG/8ML SOLN 8 ML VIAL,128748,CDM,636,RC,J9171,HCPCS,66758005002,NDC,facility,both,1,ME,,13.52,10.14,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16ML SOLN 16 ML VIAL,128749,CDM,636,RC,J9171,HCPCS,66758005003,NDC,facility,both,1,ME,,12.82,9.61,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16ML SOLN 16 ML VIAL,128749,CDM,636,RC,J9171,HCPCS,67457053316,NDC,facility,both,1,ME,,7.21,5.41,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16ML SOLN 16 ML VIAL,128749,CDM,636,RC,J9171,HCPCS,409020120,NDC,facility,both,1,ME,,2.23,1.67,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16ML SOLN 8 ML VIAL,128749,CDM,636,RC,J9171,HCPCS,66758005002,NDC,facility,both,1,ME,,12.63,9.47,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16ML SOLN 8 ML VIAL,128749,CDM,636,RC,J9171,HCPCS,409020110,NDC,facility,both,1,ME,,11.02,8.26,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 5 MG/ML SOLN 10 ML VIAL,128796,CDM,636,RC,J9228,HCPCS,3232711,NDC,facility,both,1,ME,,467.9,350.92,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 5 MG/ML SOLN 10 ML VIAL,128797,CDM,636,RC,J9228,HCPCS,3232711,NDC,facility,both,1,ME,,453.38,340.03,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 5 MG/ML SOLN 40 ML VIAL,128797,CDM,636,RC,J9228,HCPCS,3232822,NDC,facility,both,1,ME,,435.26,326.44,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 300 MG TB24,129121,CDM,250,RC,16714062701,NDC,,,facility,both,1,UN,,25.35,19.01,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 300 MG TB24,129121,CDM,250,RC,16714062701,NDC,,,facility,both,2,UN,,20.3,15.22,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 16 % OINT 113 G TUBE,129136,CDM,250,RC,62103033304,NDC,,,facility,both,113,GR,,46.4,34.8,,,,,,,,,,Gross Charge Type: Pharmacy
ROFLUMILAST 500 MCG TABS,129465,CDM,250,RC,310009530,NDC,,,facility,both,0.5,UN,,20.55,15.41,,,,,,,,,,Gross Charge Type: Pharmacy
ROFLUMILAST 500 MCG TABS,129465,CDM,250,RC,310009530,NDC,,,facility,both,1,UN,,31.65,23.74,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 10 MG TABS,129466,CDM,250,RC,72205026030,NDC,,,facility,both,3,UN,,4.43,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 10 MG TABS,129466,CDM,250,RC,456111030,NDC,,,facility,both,3,UN,,21.67,16.25,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 10 MG TABS,129466,CDM,250,RC,72205026030,NDC,,,facility,both,2,UN,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 10 MG TABS,129466,CDM,250,RC,456111030,NDC,,,facility,both,1,UN,,27.82,20.86,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 10 MG TABS,129466,CDM,250,RC,72205026030,NDC,,,facility,both,4,UN,,3.76,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 10 MG TABS,129466,CDM,250,RC,456111030,NDC,,,facility,both,4,UN,,19.93,14.94,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 10 MG TABS,129466,CDM,250,RC,456111030,NDC,,,facility,both,2,UN,,22.09,16.57,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 10 MG TABS,129466,CDM,250,RC,72205026030,NDC,,,facility,both,1,UN,,9.6,7.2,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 40 MG TABS,129468,CDM,250,RC,456114030,NDC,,,facility,both,0.5,UN,,18.45,13.84,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 40 MG TABS,129468,CDM,250,RC,456114030,NDC,,,facility,both,1,UN,,27.58,20.68,,,,,,,,,,Gross Charge Type: Pharmacy
LINAGLIPTIN 5 MG TABS,129575,CDM,250,RC,597014030,NDC,,,facility,both,1,UN,,34.54,25.91,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 360 MG IN 200 ML D5W 360-4.14 MG/200ML-% SOLN,129913,CDM,636,RC,J0283,HCPCS,43066036020,NDC,facility,both,30,ME,,14.68,11.01,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 360 MG IN 200 ML D5W 360-4.14 MG/200ML-% SOLN,129913,CDM,636,RC,J0282,HCPCS,43066036020,NDC,facility,both,30,ME,,13.92,10.44,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG TABS,130001,CDM,250,RC,52015008001,NDC,,,facility,both,1,UN,,190,142.5,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG TABS,130775,CDM,250,RC,50458058010,NDC,,,facility,both,1,UN,,30.69,23.02,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG TABS,130775,CDM,250,RC,50458058010,NDC,,,facility,both,1.5,UN,,19.85,14.89,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG TABS,130778,CDM,250,RC,186077739,NDC,,,facility,both,6.666666667,UN,,12.64,9.48,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG TABS,130778,CDM,250,RC,186077739,NDC,,,facility,both,4,UN,,14.38,10.78,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG TABS,130778,CDM,250,RC,186077739,NDC,,,facility,both,1,UN,,21.42,16.06,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG TABS,130778,CDM,250,RC,186077739,NDC,,,facility,both,2,UN,,16.64,12.48,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 10 MG TABS,13086,CDM,250,RC,59762005601,NDC,,,facility,both,2,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 10 MG TABS,13086,CDM,250,RC,59762005601,NDC,,,facility,both,1,UN,,7.7,5.78,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 10 MG TABS,13086,CDM,250,RC,60687010521,NDC,,,facility,both,2,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 10 MG TABS,13086,CDM,250,RC,60687010521,NDC,,,facility,both,1,UN,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 2.5 MG TABS,13087,CDM,250,RC,555087202,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 2.5 MG TABS,13087,CDM,250,RC,555087202,NDC,,,facility,both,2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 6 MG/ML SUSR,130945,CDM,250,RC,MHS1ML,HCPCS,4082205,NDC,facility,both,1,ML,,4.46,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 6 MG/ML SUSR,130945,CDM,250,RC,MHS1ML,HCPCS,42291056760,NDC,facility,both,1,ML,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
"Hc Room Med-Surg Semi Private, Three To Four Beds",1310000001,CDM,131,RC,,,,,facility,both,,,,1811,1358.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Room Telemetry Med-Surg Semi Private, Three To Four",1310000002,CDM,131,RC,,,,,facility,both,,,,2256,1692,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
TPN ELECTROLYTES CONC 20 ML VIAL,131312,CDM,636,RC,409577901,NDC,,,facility,both,30,ML,,32.68,24.51,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 30 GM/300 ML (10 %) SOLN,131359,CDM,636,RC,J1569,HCPCS,944270007,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 30 GM/300 ML (10 %) SOLN,131359,CDM,636,RC,J1569,HCPCS,944270005,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 30 GM/300 ML (10 %) SOLN,131359,CDM,636,RC,J1569,HCPCS,944270006,NDC,facility,both,500,ME,,91.68,68.76,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB 5 MG/ML SOLR 1 EACH VIAL,131509,CDM,636,RC,J9042,HCPCS,51144005001,NDC,facility,both,1,ME,,600.8,450.6,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 324 (65 FE) MG TBEC,131762,CDM,250,RC,574060801,NDC,,,facility,both,3,UN,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 324 (65 FE) MG TBEC,131762,CDM,250,RC,574060811,NDC,,,facility,both,2.00617284,UN,,2.38,1.79,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 324 (65 FE) MG TBEC,131762,CDM,250,RC,574060811,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 324 (65 FE) MG TBEC,131762,CDM,250,RC,574060811,NDC,,,facility,both,1.00308642,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 324 (65 FE) MG TBEC,131762,CDM,250,RC,574060801,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 324 (65 FE) MG TBEC,131762,CDM,250,RC,574060811,NDC,,,facility,both,2,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 324 (65 FE) MG TBEC,131762,CDM,250,RC,574060811,NDC,,,facility,both,3,UN,,2.57,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 324 (65 FE) MG TBEC,131762,CDM,250,RC,574060801,NDC,,,facility,both,1.00308642,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
IBANDRONATE 1 MG/ML SOLN,131763,CDM,636,RC,J1740,HCPCS,60505609700,NDC,facility,both,1,ME,,232.35,174.26,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXOCOBALAMIN 5 G SOLR 1 EACH BOX,131807,CDM,250,RC,50633031011,NDC,,,facility,both,25,ME,,2111.9,1583.92,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXOCOBALAMIN 5 G SOLR 1 EACH BOX,131807,CDM,250,RC,J3425,HCPCS,50633031011,NDC,facility,both,25,ME,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 2.8 G SUPP,131819,CDM,250,RC,132019012,NDC,,,facility,both,4,ML,,21.8,16.35,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/100 ML SOLN,131834,CDM,636,RC,J3489,HCPCS,25021082682,NDC,facility,both,1,ME,,28.31,21.23,,,,,,,,,,Gross Charge Type: Pharmacy
AQUAPHOR ADVANCED THERAPY OINT,131849,CDM,250,RC,72140063608,NDC,,,facility,both,1,GR,,21.2,15.9,,,,,,,,,,Gross Charge Type: Pharmacy
AQUAPHOR ADVANCED THERAPY OINT 85 G TUBE,131849,CDM,250,RC,72140063377,NDC,,,facility,both,1,GR,,22.7,17.02,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 10 MG TABS,132170,CDM,250,RC,16714088701,NDC,,,facility,both,2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 10 MG TABS,132170,CDM,250,RC,16714088701,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 10 MG TABS,132170,CDM,250,RC,16714088701,NDC,,,facility,both,1.5,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 10 MG TABS,132170,CDM,250,RC,16714088701,NDC,,,facility,both,0.5,UN,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE 25 MG/ML SOLN,13218,CDM,636,RC,J2175,HCPCS,641605225,NDC,facility,both,100,ME,,37.34,28,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE 25 MG/ML SOLN,13218,CDM,636,RC,J2175,HCPCS,409117630,NDC,facility,both,100,ME,,41,30.75,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE 50 MG/ML SOLN,13219,CDM,636,RC,J2175,HCPCS,641605325,NDC,facility,both,100,ME,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE LIPOSOME 1.3 % 1.3 % SUSP,132249,CDM,636,RC,C9290,HCPCS,65250026604,NDC,facility,both,1,ME,,4.07,3.05,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE LIPOSOME 1.3 % 1.3 % SUSP,132249,CDM,636,RC,C9290,HCPCS,65250026609,NDC,facility,both,1,ME,,4.17,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 38 MG/ML SOLN 5.26 ML VIAL,132254,CDM,636,RC,J9201,HCPCS,409018301,NDC,facility,both,200,ME,,17.31,12.98,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 38 MG/ML SOLN 5.26 ML VIAL,132254,CDM,636,RC,J9201,HCPCS,71288011706,NDC,facility,both,200,ME,,29.15,21.86,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 38 MG/ML SOLN 26.3 ML VIAL,132255,CDM,636,RC,J9201,HCPCS,71288011728,NDC,facility,both,200,ME,,16.9,12.68,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 38 MG/ML SOLN 26.3 ML VIAL,132255,CDM,636,RC,J9201,HCPCS,409018101,NDC,facility,both,200,ME,,10.42,7.81,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 38 MG/ML SOLN 26.3 ML VIAL,132255,CDM,636,RC,J9201,HCPCS,67457061730,NDC,facility,both,200,ME,,22.79,17.09,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 38 MG/ML SOLN 52.6 ML VIAL,132256,CDM,636,RC,J9201,HCPCS,409018201,NDC,facility,both,200,ME,,10.94,8.2,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG TABS,132302,CDM,250,RC,50458057810,NDC,,,facility,both,1,UN,,30.61,22.96,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG TABS,132303,CDM,250,RC,50458057910,NDC,,,facility,both,0.625,UN,,22.25,16.69,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG TABS,132303,CDM,250,RC,50458057910,NDC,,,facility,both,0.75,UN,,26.3,19.72,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG TABS,132303,CDM,250,RC,50458057910,NDC,,,facility,both,1,UN,,30.8,23.1,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG TABS,132303,CDM,250,RC,50458057910,NDC,,,facility,both,0.5,UN,,17.89,13.42,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG SOLR,132461,CDM,250,RC,63323064907,NDC,,,facility,both,0.75,UN,,210.35,157.76,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 2 MG/ML SOLN,13331,CDM,250,RC,MHS0.5ML,HCPCS,54355663,NDC,facility,both,0.5,ML,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,406577162,NDC,,,facility,both,10,UN,,1.18,0.88,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,406577162,NDC,,,facility,both,1,UN,,5.83,4.37,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,406577162,NDC,,,facility,both,9,UN,,1.24,0.93,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,54071020,NDC,,,facility,both,0.5,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,54071020,NDC,,,facility,both,3,UN,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,406577162,NDC,,,facility,both,0.5,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,406577162,NDC,,,facility,both,4,UN,,0.66,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,406577162,NDC,,,facility,both,2,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,54071020,NDC,,,facility,both,1,UN,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,54071020,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,406577162,NDC,,,facility,both,3,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG TABS,13333,CDM,250,RC,406577162,NDC,,,facility,both,1.5,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 5 MG TABS,13335,CDM,250,RC,406575562,NDC,,,facility,both,2,UN,,3.02,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 5 MG TABS,13335,CDM,250,RC,406575562,NDC,,,facility,both,1,UN,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 5 MG TABS,13335,CDM,250,RC,406575562,NDC,,,facility,both,0.5,UN,,5.4,4.05,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 5 MG TABS,13335,CDM,250,RC,406575562,NDC,,,facility,both,4,UN,,1.74,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 5 MG TABS,13335,CDM,250,RC,406575562,NDC,,,facility,both,1.5,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (ANORECTAL) 5 % GEL 10 G TUBE,133399,CDM,250,RC,63135058110,NDC,,,facility,both,10,GR,,51.8,38.85,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/100ML SOLN,133508,CDM,636,RC,J1953,HCPCS,55150024647,NDC,facility,both,10,ME,,1.6,1.2,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/100ML SOLN,133508,CDM,636,RC,J1953,HCPCS,67457025510,NDC,facility,both,10,ME,,1.71,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/100ML SOLN,133508,CDM,636,RC,J1953,HCPCS,43598063510,NDC,facility,both,10,ME,,1.46,1.1,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 1000 MG/100ML SOLN,133509,CDM,636,RC,J1953,HCPCS,67457026510,NDC,facility,both,10,ME,,1.04,0.78,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 1000 MG/100ML SOLN,133509,CDM,636,RC,J1953,HCPCS,43598063610,NDC,facility,both,10,ME,,0.86,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 1500 MG/100ML SOLN,133510,CDM,636,RC,J1953,HCPCS,43598063710,NDC,facility,both,10,ME,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
METHENAMINE MANDELATE 0.5 GM TABS,13352,CDM,250,RC,42799010501,NDC,,,facility,both,2,UN,,5.22,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG TABS,133585,CDM,250,RC,904735504,NDC,,,facility,both,2,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG TABS,133585,CDM,250,RC,904735504,NDC,,,facility,both,3,UN,,4.03,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG TABS,133585,CDM,250,RC,904735504,NDC,,,facility,both,1,UN,,8.57,6.42,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG TABS,133585,CDM,250,RC,63402030230,NDC,,,facility,both,1,UN,,80.89,60.67,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG TABS,133585,CDM,250,RC,63402030230,NDC,,,facility,both,3,UN,,71.25,53.44,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG TABS,133585,CDM,250,RC,63402030230,NDC,,,facility,both,2,UN,,74.95,56.21,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG TABS,133585,CDM,250,RC,63402030230,NDC,,,facility,both,1.5,UN,,58.45,43.84,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG TABS,133585,CDM,250,RC,63402030230,NDC,,,facility,both,4,UN,,69.4,52.05,,,,,,,,,,Gross Charge Type: Pharmacy
TUBING - PRIMARY NTG PUMP MISC 50 EACH BOX,1336,CDM,250,RC,16784070312,NDC,,,facility,both,1,UN,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,31722053301,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,60687055901,NDC,,,facility,both,0.5,UN,,6.69,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,60687055901,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,70010075401,NDC,,,facility,both,1.5,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,31722053301,NDC,,,facility,both,1.5,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,70010075405,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,60687055901,NDC,,,facility,both,1.5,UN,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,70010075401,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,904705761,NDC,,,facility,both,1.5,UN,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,60687055901,NDC,,,facility,both,1,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,904705761,NDC,,,facility,both,2,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,50268052015,NDC,,,facility,both,1,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,60687055901,NDC,,,facility,both,3,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,904705761,NDC,,,facility,both,1,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,70010075401,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,13364,CDM,250,RC,70010075401,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS 100 EACH BOTTLE,13364,CDM,250,RC,70010075401,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS 100 EACH BOTTLE,13364,CDM,250,RC,70010075401,NDC,,,facility,both,3,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,63739099210,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,60687056801,NDC,,,facility,both,0.3333,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,904705861,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,904705861,NDC,,,facility,both,0.666666667,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,76385012401,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,60687056801,NDC,,,facility,both,2,UN,,4.42,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,63739099210,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,31722053401,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,60687056801,NDC,,,facility,both,0.5,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,60687056801,NDC,,,facility,both,0.666666667,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,904705861,NDC,,,facility,both,1,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,76385012401,NDC,,,facility,both,0.666666667,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,904705861,NDC,,,facility,both,0.5,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG TABS,13365,CDM,250,RC,60687056801,NDC,,,facility,both,1,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SOLR 1 EACH VIAL,13371,CDM,636,RC,J9260,HCPCS,63323012250,NDC,facility,both,50,ME,,11.68,8.76,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG TABS,13408,CDM,250,RC,10702010101,NDC,,,facility,both,2,UN,,2.9,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG TABS,13408,CDM,250,RC,10702010101,NDC,,,facility,both,1.5,UN,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG TABS,13408,CDM,250,RC,68084082321,NDC,,,facility,both,2,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG TABS,13408,CDM,250,RC,10702010101,NDC,,,facility,both,1,UN,,5.29,3.97,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG TABS,13408,CDM,250,RC,68084082321,NDC,,,facility,both,1,UN,,7.3,5.47,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 5 MG TABS,13410,CDM,250,RC,406114201,NDC,,,facility,both,3,UN,,2.13,1.6,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 5 MG TABS,13410,CDM,250,RC,10702010001,NDC,,,facility,both,0.5,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 5 MG TABS,13410,CDM,250,RC,406114201,NDC,,,facility,both,2,UN,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 5 MG TABS,13410,CDM,250,RC,78043905,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 5 MG TABS,13410,CDM,250,RC,68084080521,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 5 MG TABS,13410,CDM,250,RC,10702010001,NDC,,,facility,both,1,UN,,5.4,4.05,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 5 MG TABS,13410,CDM,250,RC,78043905,NDC,,,facility,both,0.5,UN,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 5 MG TABS,13410,CDM,250,RC,68084080521,NDC,,,facility,both,0.5,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 4 MG TABS,13416,CDM,636,RC,J7509,HCPCS,68084014901,NDC,facility,both,4,ME,,6.81,5.11,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,13418,CDM,70121157305,NDC,,,,,facility,both,1,ML,,23,17.25,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,13418,CDM,9307301,NDC,,,,,facility,both,1,ML,,34.54,25.91,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,13418,CDM,9307301,NDC,,,,,facility,both,1,ML,,1.52,1.14,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSP,13418,CDM,636,RC,J1030,HCPCS,9307301,NDC,facility,both,1,ME,,35.35,26.51,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSP,13418,CDM,636,RC,J1010,HCPCS,9307301,NDC,facility,both,1,ME,,1.55,1.16,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSP,13418,CDM,636,RC,J1030,HCPCS,70121157305,NDC,facility,both,1,ME,,40.52,30.39,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSP 1 ML VIAL,13418,CDM,636,RC,J1030,HCPCS,9307301,NDC,facility,both,1,ME,,59.55,44.66,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSP 1 ML VIAL,13418,CDM,636,RC,J1010,HCPCS,9307301,NDC,facility,both,1,ME,,1.49,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,13419,CDM,9347501,NDC,,,,,facility,both,1,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,13419,CDM,70121157405,NDC,,,,,facility,both,1,ML,,54.77,41.08,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,13419,CDM,60219157401,NDC,,,,,facility,both,1,ML,,40,30,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,13419,CDM,70121157401,NDC,,,,,facility,both,1,ML,,43.23,32.42,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,13419,CDM,70121157405,NDC,,,,,facility,both,1,ML,,0.82,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,13419,CDM,9347501,NDC,,,,,facility,both,1,ML,,64.93,48.7,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,13419,CDM,70121157401,NDC,,,,,facility,both,1,ML,,0.82,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSP,13419,CDM,636,RC,J1040,HCPCS,9347501,NDC,facility,both,1,ME,,71.79,53.84,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSP,13419,CDM,636,RC,J1010,HCPCS,70121157405,NDC,facility,both,1,ME,,0.82,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSP,13419,CDM,636,RC,J1040,HCPCS,70121157405,NDC,facility,both,1,ME,,34.17,25.62,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSP,13419,CDM,636,RC,J1010,HCPCS,9347501,NDC,facility,both,1,ME,,1.09,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 5 MG/ML SOLN,13439,CDM,636,RC,J2765,HCPCS,703450204,NDC,facility,both,10,ME,,44.15,33.11,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 5 MG/ML SOLN,13439,CDM,636,RC,J2765,HCPCS,409341401,NDC,facility,both,10,ME,,33.4,25.05,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 5 MG/ML SOLN 2 ML VIAL,13439,CDM,636,RC,J2765,HCPCS,409341401,NDC,facility,both,10,ME,,33.45,25.09,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG TABS,13442,CDM,250,RC,51079088820,NDC,,,facility,both,0.25,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG TABS,13442,CDM,250,RC,60687063101,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG TABS,13442,CDM,250,RC,51079088820,NDC,,,facility,both,0.5,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG TABS,13442,CDM,250,RC,60687063101,NDC,,,facility,both,0.25,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG TABS,13442,CDM,250,RC,60687063101,NDC,,,facility,both,0.5,UN,,7.7,5.78,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG TABS,13442,CDM,250,RC,51079088820,NDC,,,facility,both,1,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 5 MG TABS,13443,CDM,250,RC,51079088620,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 5 MG TABS,13443,CDM,250,RC,51079088620,NDC,,,facility,both,0.5,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 5 MG TABS,13443,CDM,250,RC,51079088620,NDC,,,facility,both,2,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TABS,13448,CDM,250,RC,62584026601,NDC,,,facility,both,4,UN,,2.12,1.59,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TABS,13448,CDM,250,RC,62584026601,NDC,,,facility,both,2,UN,,3.59,2.69,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TABS,13448,CDM,250,RC,62584026601,NDC,,,facility,both,1.5,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TABS,13448,CDM,250,RC,62584026601,NDC,,,facility,both,3,UN,,2.65,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TABS,13448,CDM,250,RC,62584026601,NDC,,,facility,both,0.5,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TABS,13448,CDM,250,RC,51079080120,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TABS,13448,CDM,250,RC,62584026601,NDC,,,facility,both,1,UN,,6.18,4.64,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TABS,13448,CDM,250,RC,51079080120,NDC,,,facility,both,2,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
TRAVOPROST 0.004 % SOLN 2.5 ML BOTTLE,134514,CDM,250,RC,42571013027,NDC,,,facility,both,2.5,ML,,230.4,172.8,,,,,,,,,,Gross Charge Type: Pharmacy
TRAVOPROST 0.004 % SOLN 2.5 ML BOTTLE,134514,CDM,250,RC,60505059304,NDC,,,facility,both,2.5,ML,,180.5,135.38,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % NEBU,134515,CDM,250,RC,487590199,NDC,,,facility,both,0.25,ML,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % NEBU,134515,CDM,250,RC,487590199,NDC,,,facility,both,1,ML,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % NEBU,134515,CDM,250,RC,487590199,NDC,,,facility,both,0.39,ML,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % NEBU,134515,CDM,250,RC,487590199,NDC,,,facility,both,0.38,ML,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % NEBU,134515,CDM,250,RC,487590199,NDC,,,facility,both,0.37,ML,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % NEBU,134515,CDM,250,RC,487590199,NDC,,,facility,both,0.43,ML,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % NEBU,134515,CDM,250,RC,487590199,NDC,,,facility,both,0.35,ML,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % NEBU,134515,CDM,250,RC,487590199,NDC,,,facility,both,0.5,ML,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,904712661,NDC,,,facility,both,4,UN,,3.19,2.39,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,60687055001,NDC,,,facility,both,0.5,UN,,7.7,5.78,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,29300022746,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,29300022701,NDC,,,facility,both,4,UN,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,29300022746,NDC,,,facility,both,2,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,29300022746,NDC,,,facility,both,4,UN,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,60687055001,NDC,,,facility,both,4,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,904712661,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,29300022701,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG TABS,13461,CDM,250,RC,60687055001,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
MICONAZOLE 2 % CREA,13514,CDM,250,RC,61269073556,NDC,,,facility,both,1,GR,,31.39,23.54,,,,,,,,,,Gross Charge Type: Pharmacy
MICONAZOLE 2 % CREA 45 G TUBE,13515,CDM,250,RC,51672203506,NDC,,,facility,both,45,GR,,32.9,24.68,,,,,,,,,,Gross Charge Type: Pharmacy
TUBING - PRIMARY PUMP MISC 1 EACH BOX,1352,CDM,250,RC,741422928,NDC,,,facility,both,1,UN,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"Hc Room Detoxification Semi Private, Three To Four Beds",1360000001,CDM,136,RC,,,,,facility,both,,,,2779,2084.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
MINERAL OIL OIL,13616,CDM,250,RC,MHS1ML,HCPCS,10939074444,NDC,facility,both,1,ML,,0.54,0.4,,,,,,,,,,Gross Charge Type: Pharmacy
PERTUZUMAB 30 MG/ML SOLN 14 ML VIAL,136483,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,both,1,ME,,42.28,31.71,,,,,,,,,,Gross Charge Type: Pharmacy
MINOCYCLINE 50 MG CAPS,13651,CDM,250,RC,65862020901,NDC,,,facility,both,1,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
MINOCYCLINE 50 MG CAPS,13651,CDM,250,RC,65862020901,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
MINOCYCLINE 50 MG CAPS,13651,CDM,250,RC,65862020901,NDC,,,facility,both,4,UN,,2.46,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL 10 MG TABS,13656,CDM,250,RC,68084020501,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL 10 MG TABS,13656,CDM,250,RC,68084020501,NDC,,,facility,both,2,UN,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL 10 MG TABS,13656,CDM,250,RC,49884025701,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL 2.5 MG TABS,13657,CDM,250,RC,68084020401,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL 2.5 MG TABS,13657,CDM,250,RC,49884025601,NDC,,,facility,both,2,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL 2.5 MG TABS,13657,CDM,250,RC,49884025601,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL 2.5 MG TABS,13657,CDM,250,RC,68084020401,NDC,,,facility,both,0.5,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT AERS 4 G INHALER,136589,CDM,250,RC,597002402,NDC,,,facility,both,4,GR,,559.25,419.44,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS CAPS,136648,CDM,250,RC,49100040007,NDC,,,facility,both,1,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS CAPS,136648,CDM,250,RC,49100040007,NDC,,,facility,both,2,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML CONC 1 ML VIAL,136979,CDM,636,RC,J9171,HCPCS,25021024501,NDC,facility,both,1,ME,,2.2,1.65,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML CONC 4 ML VIAL,136979,CDM,636,RC,J9171,HCPCS,25021024504,NDC,facility,both,1,ME,,1.69,1.27,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML CONC 4 ML VIAL,136979,CDM,636,RC,J9171,HCPCS,45963076552,NDC,facility,both,1,ME,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML CONC 4 ML VIAL,136979,CDM,636,RC,J9171,HCPCS,143920501,NDC,facility,both,1,ME,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML CONC 8 ML VIAL,136979,CDM,636,RC,J9171,HCPCS,16729026765,NDC,facility,both,1,ME,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML CONC 8 ML VIAL,136979,CDM,636,RC,J9171,HCPCS,67457078108,NDC,facility,both,1,ME,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN,137046,CDM,636,RC,J9250,HCPCS,16729027730,NDC,facility,both,50,ME,,1.75,1.31,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN,137046,CDM,636,RC,J9255,HCPCS,16729027730,NDC,facility,both,50,ME,,12.72,9.54,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN,137046,CDM,636,RC,J9250,HCPCS,703367101,NDC,facility,both,50,ME,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN,137046,CDM,636,RC,J9250,HCPCS,143951910,NDC,facility,both,50,ME,,1.39,1.04,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN,137046,CDM,636,RC,J9260,HCPCS,16729027730,NDC,facility,both,50,ME,,18.05,13.54,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN 2 ML VIAL,137046,CDM,636,RC,J9250,HCPCS,143951910,NDC,facility,both,50,ME,,0.8,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN 2 ML VIAL,137046,CDM,636,RC,J9260,HCPCS,16729027730,NDC,facility,both,50,ME,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN 2 ML VIAL,137046,CDM,636,RC,J9255,HCPCS,16729027730,NDC,facility,both,50,ME,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN 2 ML VIAL,137046,CDM,636,RC,J9250,HCPCS,16729027730,NDC,facility,both,50,ME,,1.4,1.05,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN 2 ML VIAL,137046,CDM,636,RC,J9250,HCPCS,703367101,NDC,facility,both,50,ME,,2.28,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN 40 ML VIAL,137048,CDM,636,RC,J9255,HCPCS,16729027735,NDC,facility,both,50,ME,,3.49,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN 40 ML VIAL,137048,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,both,50,ME,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 2 MG/ML SOLR 1 EACH VIAL,137061,CDM,636,RC,J9047,HCPCS,76075010101,NDC,facility,both,1,ME,,144.63,108.47,,,,,,,,,,Gross Charge Type: Pharmacy
MIRABEGRON ER 25 MG TB24,137270,CDM,250,RC,469260130,NDC,,,facility,both,2,UN,,27.85,20.89,,,,,,,,,,Gross Charge Type: Pharmacy
MIRABEGRON ER 25 MG TB24,137270,CDM,250,RC,469260130,NDC,,,facility,both,1,UN,,33.15,24.86,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.4,ML,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.2,ML,,5.4,4.05,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.175,ML,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.15,ML,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.5,ML,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.75,ML,,5.9,4.42,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.375,ML,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.3,ML,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,1,ML,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.1,ML,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.25,ML,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG/5ML SOLN,137489,CDM,250,RC,54051750,NDC,,,facility,both,0.125,ML,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE PF (PRES-FREE) 10 MG/ML SOLN,137700,CDM,636,RC,J1100,HCPCS,55150030425,NDC,facility,both,1,ME,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE PF (PRES-FREE) 10 MG/ML SOLN,137700,CDM,636,RC,J1100,HCPCS,70069002125,NDC,facility,both,1,ME,,4.34,3.25,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE PF (PRES-FREE) 10 MG/ML SOLN,137700,CDM,636,RC,J1100,HCPCS,63323050601,NDC,facility,both,1,ME,,6.53,4.9,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE PF (PRES-FREE) 10 MG/ML SOLN 1 ML VIAL,137700,CDM,636,RC,J1100,HCPCS,55150030425,NDC,facility,both,1,ME,,3.42,2.56,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE PF (PRES-FREE) 10 MG/ML SOLN 1 ML VIAL,137700,CDM,636,RC,J1100,HCPCS,70069002125,NDC,facility,both,1,ME,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,137700,CDM,63323050601,NDC,,,,,facility,both,1,ML,,1.3,0.98,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE PF 1 MG/ML SOLN,137724,CDM,636,RC,J1170,HCPCS,63323085225,NDC,facility,both,0.1,ME,,43.45,32.59,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE PF 1 MG/ML SOLN 1 ML VIAL,137724,CDM,636,RC,J1170,HCPCS,63323085225,NDC,facility,both,0.1,ME,,64,48,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE PF 2 MG/ML SOLN 1 ML VIAL,137725,CDM,636,RC,J1170,HCPCS,63323085325,NDC,facility,both,0.1,ME,,15.68,11.76,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE PF 2 MG/ML SOLN 20 ML VIAL,137725,CDM,636,RC,J1170,HCPCS,641234139,NDC,facility,both,0.1,ME,,7.17,5.38,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE PF 10 MG/ML SOLN 1 ML VIAL,137727,CDM,636,RC,J1170,HCPCS,409263401,NDC,facility,both,0.1,ME,,12.67,9.5,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE PF 10 MG/ML SOLN 1 ML VIAL,137727,CDM,636,RC,J1170,HCPCS,409263410,NDC,facility,both,0.1,ME,,13.65,10.23,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE PF 10 MG/ML SOLN 1 ML VIAL,137727,CDM,636,RC,J1170,HCPCS,703011003,NDC,facility,both,0.1,ME,,13.86,10.39,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE PF 10 MG/ML SOLN 5 ML VIAL,137727,CDM,636,RC,J1170,HCPCS,703011303,NDC,facility,both,0.1,ME,,5.29,3.97,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE PF 4 MG/ML SOLN,137778,CDM,636,RC,J2270,HCPCS,641612525,NDC,facility,both,10,ME,,38.76,29.07,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE PF 4 MG/ML SOLN,137778,CDM,636,RC,J2270,HCPCS,409189101,NDC,facility,both,10,ME,,36.86,27.65,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE (PF) 10 MG/ML SOLN,137780,CDM,636,RC,J2270,HCPCS,409189301,NDC,facility,both,10,ME,,33.8,25.35,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE (PF) 10 MG/ML SOLN,137780,CDM,636,RC,J2270,HCPCS,641612725,NDC,facility,both,10,ME,,38.09,28.56,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 50 MG/5ML SOLN 1 ML VIAL,137956,CDM,636,RC,J1170,HCPCS,409263401,NDC,facility,both,0.1,ME,,6.28,4.71,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 50 MG/5ML SOLN 5 ML VIAL,137956,CDM,636,RC,J1170,HCPCS,703011303,NDC,facility,both,0.1,ME,,4.63,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,137977,CDM,250,RC,64980033901,NDC,,,facility,both,2,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,137977,CDM,250,RC,64980033901,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML SOLN,13812,CDM,636,RC,J2272,HCPCS,76045000411,NDC,facility,both,10,ME,,82.05,61.54,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML SOLN,13812,CDM,636,RC,J2270,HCPCS,76045000411,NDC,facility,both,10,ME,,80.1,60.08,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML SOLN,13812,CDM,636,RC,J2272,HCPCS,76045000410,NDC,facility,both,10,ME,,36.75,27.56,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,3,ML,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,3.375,ML,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,4,ML,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,121090405,NDC,,,facility,both,2.5,ML,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,22.5,ML,,3.53,2.65,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,10,ML,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,1,ML,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,121090405,NDC,,,facility,both,5,ML,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,2,ML,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,1.5,ML,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,15,ML,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,2.5,ML,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,5,ML,,7.95,5.96,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,121090405,NDC,,,facility,both,1.25,ML,,5.7,4.28,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,121090405,NDC,,,facility,both,3.75,ML,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,1.25,ML,,5.9,4.42,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/5ML SOLN,13820,CDM,250,RC,68094000162,NDC,,,facility,both,3.75,ML,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TABS,13823,CDM,250,RC,54023524,NDC,,,facility,both,2,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TABS,13823,CDM,250,RC,54023524,NDC,,,facility,both,3,UN,,3.23,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TABS,13823,CDM,250,RC,54023524,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TABS,13823,CDM,250,RC,54023524,NDC,,,facility,both,0.5,UN,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TABS,13823,CDM,250,RC,54023524,NDC,,,facility,both,4,UN,,2.8,2.1,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE 145 MCG CAPS,138234,CDM,250,RC,456120130,NDC,,,facility,both,2,UN,,31.05,23.29,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE 145 MCG CAPS,138234,CDM,250,RC,456120130,NDC,,,facility,both,1,UN,,36.35,27.26,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 30 MG TABS,13824,CDM,250,RC,832027411,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 30 MG TABS,13824,CDM,250,RC,832027411,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 2 MG/ML5ML SOLN,138256,CDM,636,RC,76329124001,NDC,,,facility,both,1,ME,,92.05,69.04,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 2 MG/ML5ML SOLN,138256,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,both,1,ME,,92.05,69.04,,,,,,,,,,Gross Charge Type: Pharmacy
ICOSAPENT ETHYL 1 G CAPS,139151,CDM,250,RC,60505403301,NDC,,,facility,both,2,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
ICOSAPENT ETHYL 1 G CAPS,139151,CDM,250,RC,60505403301,NDC,,,facility,both,1,UN,,12.95,9.71,,,,,,,,,,Gross Charge Type: Pharmacy
LETS KIT,139249,CDM,51552134501,NDC,,,,,facility,both,1,ML,,197.57,148.18,,,,,,,,,,Gross Charge Type: Pharmacy
LETS KIT,139249,CDM,51552134501,NDC,,,,,facility,both,1,ML,,41.01,30.76,,,,,,,,,,Gross Charge Type: Pharmacy
LETS KIT,139249,CDM,51552134501,NDC,,,,,facility,both,1,ML,,26,19.5,,,,,,,,,,Gross Charge Type: Pharmacy
LETS KIT,139249,CDM,51552134501,NDC,,,,,facility,both,1,ML,,26.85,20.14,,,,,,,,,,Gross Charge Type: Pharmacy
LETS KIT,139249,CDM,51552134501,NDC,,,,,facility,both,1,ML,,202.18,151.64,,,,,,,,,,Gross Charge Type: Pharmacy
LETS KIT,139249,CDM,51552134501,NDC,,,,,facility,both,1,ML,,158.78,119.08,,,,,,,,,,Gross Charge Type: Pharmacy
LETS KIT,139249,CDM,51552134501,NDC,,,,,facility,both,1,ML,,847.2,635.4,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN INJ 5 ML VIAL,139397,CDM,250,RC,54643564901,NDC,,,facility,both,10,ML,,58.42,43.82,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN INJ 5 ML VIAL,139397,CDM,250,RC,54643564901,NDC,,,facility,both,5,ML,,82.85,62.14,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG TABS,139524,CDM,250,RC,3089331,NDC,,,facility,both,1,UN,,10.9,8.18,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG TABS,139524,CDM,250,RC,3089331,NDC,,,facility,both,2,UN,,6.98,5.23,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG TABS,139524,CDM,250,RC,3089331,NDC,,,facility,both,4,UN,,4.84,3.63,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG TABS,139557,CDM,250,RC,3089421,NDC,,,facility,both,0.5,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG TABS,139557,CDM,250,RC,3089431,NDC,,,facility,both,2,UN,,6.98,5.23,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG TABS,139557,CDM,250,RC,3089421,NDC,,,facility,both,1,UN,,10.9,8.18,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG TABS,139557,CDM,250,RC,3089421,NDC,,,facility,both,2,UN,,6.98,5.23,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG TABS,139557,CDM,250,RC,3089431,NDC,,,facility,both,0.5,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG TABS,139557,CDM,250,RC,3089431,NDC,,,facility,both,1,UN,,10.9,8.17,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL-CHLORTHALIDONE 50-25 MG TABS,13956,CDM,250,RC,591578201,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,904641292,NDC,,,facility,both,0.5,UN,,5.38,4.04,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,66553000401,NDC,,,facility,both,4,UN,,1.94,1.45,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,66553000401,NDC,,,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,68084098832,NDC,,,facility,both,1.5,UN,,5.02,3.77,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,66553000401,NDC,,,facility,both,1,UN,,6.44,4.83,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,904641292,NDC,,,facility,both,4,UN,,1.56,1.17,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,FAMRXNC,HCPCS,66553000401,NDC,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,68084098832,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,66553000401,NDC,,,facility,both,1.5,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,66553000401,NDC,,,facility,both,3,UN,,2.43,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,904641292,NDC,,,facility,both,2,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,904641292,NDC,,,facility,both,3,UN,,2.07,1.55,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,68084098832,NDC,,,facility,both,2,UN,,5.42,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,904641292,NDC,,,facility,both,1.5,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG CHEW,13958,CDM,250,RC,904641292,NDC,,,facility,both,1,UN,,6.09,4.57,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 10-100 MG TABS,13959,CDM,250,RC,93970101,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 10-100 MG TABS,13959,CDM,250,RC,93970101,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 13.5 MG IU IUD,139613,CDM,50419042201,NDC,,,,,facility,both,1,EA,,1240.95,930.72,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 13.5 MG IUD,139613,CDM,636,RC,J7301,HCPCS,50419042201,NDC,facility,both,1,EA,,1350.3,1012.72,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,93970201,NDC,,,facility,both,1.5,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,60687066111,NDC,,,facility,both,1.5,UN,,4.42,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,50228045801,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,378008501,NDC,,,facility,both,2,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,50228045801,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,60687066111,NDC,,,facility,both,1,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,93970205,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,93970201,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,93970201,NDC,,,facility,both,2,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,60687066111,NDC,,,facility,both,2,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,60687066111,NDC,,,facility,both,0.5,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,93970205,NDC,,,facility,both,1,UN,,0.75,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,50228045801,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TABS,13962,CDM,250,RC,378008501,NDC,,,facility,both,0.5,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL-HYDROCHLOROTHIAZIDE 10-25 MG TABS,13995,CDM,250,RC,51672404601,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG CPDR,140000,CDM,250,RC,59762011701,NDC,,,facility,both,3,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG CPDR,140000,CDM,250,RC,59762011701,NDC,,,facility,both,1,UN,,11.5,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG CPDR,140000,CDM,250,RC,59762011701,NDC,,,facility,both,2,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG CPDR,140000,CDM,250,RC,59762011701,NDC,,,facility,both,6,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG CPDR,140000,CDM,250,RC,59762011701,NDC,,,facility,both,4,UN,,5.31,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE W/ EPI 1.5 %-1:200000 SOLN,14014,CDM,250,RC,63323048837,NDC,,,facility,both,1,ME,,42.09,31.57,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE W/ EPI 1.5 %-1:200000 SOLN,14014,CDM,250,RC,63323048807,NDC,,,facility,both,1,ME,,75.6,56.7,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE W/ EPI 1.5 %-1:200000 SOLN,14014,CDM,250,RC,409120901,NDC,,,facility,both,1,ME,,36.27,27.21,,,,,,,,,,Gross Charge Type: Pharmacy
ADO-TRASTUZUMAB EMTANSINE 100 MG SOLR 1 EACH VIAL,140151,CDM,636,RC,J9354,HCPCS,50242008801,NDC,facility,both,1,ME,,101.94,76.46,,,,,,,,,,Gross Charge Type: Pharmacy
ADO-TRASTUZUMAB EMTANSINE 20 MG/ML SOLR 1 EACH VIAL,140152,CDM,636,RC,J9354,HCPCS,50242008701,NDC,facility,both,1,ME,,107.61,80.71,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % W/ EPI 1:200000 PRES-FREE 2 % SOLN,14016,CDM,250,RC,MHS1ML,HCPCS,409318301,NDC,facility,both,1,ME,,3.39,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % W/ EPI 1:200000 PRES-FREE 2 % SOLN,14016,CDM,250,RC,MHS1ML,HCPCS,63323048902,NDC,facility,both,1,ME,,8.72,6.54,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUCCINATE 62.5 MG/ML (2 ML) SOLR,14044,CDM,636,RC,J2930,HCPCS,9004726,NDC,facility,both,5,ME,,69.45,52.09,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUCCINATE 62.5 MG/ML (2 ML) SOLR,14044,CDM,636,RC,J2930,HCPCS,9004722,NDC,facility,both,5,ME,,69.45,52.09,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUCCINATE 62.5 MG/ML (2 ML) SOLR 1 EACH VIAL,14044,CDM,636,RC,J2919,HCPCS,9004722,NDC,facility,both,5,ME,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,14044,CDM,63323025803,NDC,,,,,facility,both,5,EA,,22,16.5,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,14044,CDM,9004722,NDC,,,,,facility,both,5,EA,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,14044,CDM,9004722,NDC,,,,,facility,both,5,EA,,35.78,26.83,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG/ML SOLR,14046,CDM,636,RC,J2920,HCPCS,9003932,NDC,facility,both,5,ME,,36.89,27.67,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG/ML SOLR,14046,CDM,636,RC,J2919,HCPCS,9003928,NDC,facility,both,5,ME,,7.42,5.57,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG/ML SOLR,14046,CDM,636,RC,J2920,HCPCS,9003928,NDC,facility,both,5,ME,,54.58,40.93,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML SOLN,140472,CDM,636,RC,J2270,HCPCS,63323045201,NDC,facility,both,10,ME,,34.62,25.96,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML SOLN,140472,CDM,636,RC,J2270,HCPCS,409189001,NDC,facility,both,10,ME,,37.24,27.93,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 2 MG/ML SOLN,140473,CDM,250,RC,781315095,NDC,,,facility,both,5,ML,,81.95,61.46,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 2 MG/ML SOLN,140473,CDM,250,RC,781315095,NDC,,,facility,both,4,ML,,81.95,61.46,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 2 MG/ML SOLN,140474,CDM,250,RC,63323041710,NDC,,,facility,both,5.61,ML,,67.1,50.32,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 2 MG/ML SOLN,140474,CDM,250,RC,781315295,NDC,,,facility,both,4.14,ML,,96.25,72.19,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 2 MG/ML SOLN,140474,CDM,250,RC,781315295,NDC,,,facility,both,10,ML,,96.25,72.19,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 2 MG/ML SOLN,140474,CDM,250,RC,63323041710,NDC,,,facility,both,4.39,ML,,66.05,49.54,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 2 MG/ML SOLN,140474,CDM,250,RC,63323041710,NDC,,,facility,both,6.245,ML,,67.6,50.7,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 2 MG/ML SOLN,140474,CDM,250,RC,781315295,NDC,,,facility,both,4.355,ML,,96.25,72.19,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 2 MG/ML SOLN,140474,CDM,250,RC,63323041710,NDC,,,facility,both,10,ML,,70.75,53.06,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TBCR,140480,CDM,250,RC,904655761,NDC,,,facility,both,3,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TBCR,140480,CDM,250,RC,904655761,NDC,,,facility,both,2,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TBCR,140480,CDM,250,RC,406831562,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TBCR,140480,CDM,250,RC,406831562,NDC,,,facility,both,4,UN,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TBCR,140480,CDM,250,RC,904655761,NDC,,,facility,both,4,UN,,2.31,1.73,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TBCR,140480,CDM,250,RC,406831562,NDC,,,facility,both,3,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TBCR,140480,CDM,250,RC,406831562,NDC,,,facility,both,2,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 15 MG TBCR,140480,CDM,250,RC,904655761,NDC,,,facility,both,1,UN,,6.18,4.64,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 60 MG TBCR,140481,CDM,250,RC,406838062,NDC,,,facility,both,0.25,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 60 MG TBCR,140481,CDM,250,RC,406838062,NDC,,,facility,both,1.25,UN,,4.78,3.58,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 60 MG TBCR,140481,CDM,250,RC,406838062,NDC,,,facility,both,1,UN,,8.18,6.14,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG TBCR,140482,CDM,250,RC,406839062,NDC,,,facility,both,1,UN,,11.34,8.51,,,,,,,,,,Gross Charge Type: Pharmacy
REFRESH OINT 3.5 G TUBE,140999,CDM,250,RC,23031204,NDC,,,facility,both,3.5,GR,,42,31.5,,,,,,,,,,Gross Charge Type: Pharmacy
REFRESH OINT 3.5 G TUBE,140999,CDM,250,RC,65051801,NDC,,,facility,both,3.5,GR,,36.5,27.38,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 14 MG CP24,141004,CDM,250,RC,68382054706,NDC,,,facility,both,1,UN,,12.35,9.26,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 14 MG CP24,141004,CDM,250,RC,68382054706,NDC,,,facility,both,2,UN,,8.28,6.21,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5-25 MG CAPS,14136,CDM,250,RC,51079093520,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
ARTIFICIAL TEARS 83-15 % OINT 3.5 G TUBE,141762,CDM,250,RC,65050935,NDC,,,facility,both,3.5,GR,,26.65,19.99,,,,,,,,,,Gross Charge Type: Pharmacy
ARTIFICIAL TEARS 83-15 % OINT 3.5 G TUBE,141762,CDM,250,RC,65051801,NDC,,,facility,both,3.5,GR,,36.5,27.38,,,,,,,,,,Gross Charge Type: Pharmacy
"PROTHROMBIN COMPLEX CONCENTRATE, 4 FACTOR 500 UNITS KIT",141780,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,both,1,UN,,4.96,3.72,,,,,,,,,,Gross Charge Type: Pharmacy
"PROTHROMBIN COMPLEX CONCENTRATE, 4 FACTOR 500 UNITS KIT 500 UNITS BOX",141780,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,both,1,UN,,4.96,3.72,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 40 GM/400 ML (10 %) SOLN,141807,CDM,636,RC,J1459,HCPCS,44206043820,NDC,facility,both,500,ME,,87.55,65.66,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 40 GM/400 ML (10 %) SOLN,141807,CDM,636,RC,J1459,HCPCS,44206043940,NDC,facility,both,500,ME,,87.55,65.66,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUNE GLOBULIN (HUMAN) 40 GM/400 ML (10 %) SOLN 400 ML VIAL,141807,CDM,636,RC,J1459,HCPCS,44206043940,NDC,facility,both,500,ME,,87.55,65.66,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 20,000 UNITS/ML SOLN",14183,CDM,636,RC,J0885,HCPCS,55513047810,NDC,facility,both,1000,UN,,51.17,38.38,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 20,000 UNITS/ML SOLN",14183,CDM,636,RC,J0885,HCPCS,59676032004,NDC,facility,both,1000,UN,,39.85,29.89,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 20,000 UNITS/ML SOLN 1 ML VIAL",14183,CDM,636,RC,J0885,HCPCS,59676032004,NDC,facility,both,1000,UN,,43.61,32.71,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 20000 UNIT/ML IJ SOLN,14183,CDM,59676032004,NDC,,,,,facility,both,1000,ML,,40.03,30.02,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG TABS,14184,CDM,250,RC,904641861,NDC,,,facility,both,2.5,UN,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG TABS,14184,CDM,250,RC,904641861,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG TABS,14184,CDM,250,RC,904641861,NDC,,,facility,both,0.5,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG TABS,14184,CDM,250,RC,904641861,NDC,,,facility,both,3,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG TABS,14184,CDM,250,RC,904641861,NDC,,,facility,both,2,UN,,4.82,3.62,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG TABS,14184,CDM,250,RC,904641861,NDC,,,facility,both,1.5,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
FOSFOMYCIN 3 G PACK,14185,CDM,250,RC,69097057967,NDC,,,facility,both,1,UN,,85.17,63.88,,,,,,,,,,Gross Charge Type: Pharmacy
FOSFOMYCIN 3 G PACK,14185,CDM,250,RC,67877074957,NDC,,,facility,both,1,UN,,117,87.75,,,,,,,,,,Gross Charge Type: Pharmacy
FOSFOMYCIN 3 G PACK,14185,CDM,250,RC,70700026894,NDC,,,facility,both,1,UN,,133.95,100.46,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG/ML CONC,14234,CDM,636,RC,J8540,HCPCS,54317644,NDC,facility,both,0.25,ME,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL 20 MG TABS,14306,CDM,250,RC,60687030225,NDC,,,facility,both,0.5,UN,,10.8,8.1,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL 20 MG TABS,14306,CDM,250,RC,60687030225,NDC,,,facility,both,1,UN,,13.7,10.28,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL 20 MG TABS,14306,CDM,250,RC,60687030225,NDC,,,facility,both,2,UN,,9.45,7.09,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL 40 MG TABS,14307,CDM,250,RC,76385013401,NDC,,,facility,both,1,UN,,8.3,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL 40 MG TABS,14307,CDM,250,RC,76385013401,NDC,,,facility,both,2,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL 40 MG TABS,14307,CDM,250,RC,76385013401,NDC,,,facility,both,4,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 1 GM SOLR 1 EACH VIAL,14312,CDM,250,RC,44567022110,NDC,,,facility,both,2,UN,,52.95,39.71,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 1 GM SOLR 1 EACH VIAL,14312,CDM,250,RC,55150012215,NDC,,,facility,both,1,UN,,61,45.75,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN SOLR 1 EACH VIAL,14314,CDM,250,RC,55150012316,NDC,,,facility,both,1,UN,,64.75,48.56,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN SOLR 1 EACH VIAL,14314,CDM,250,RC,55150012315,NDC,,,facility,both,1,UN,,64.75,48.56,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN SOLR 1 EACH VIAL,14314,CDM,250,RC,72485040601,NDC,,,facility,both,1,UN,,73.4,55.05,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN SOLR 1 EACH VIAL,14314,CDM,250,RC,67850003200,NDC,,,facility,both,1,UN,,69.7,52.28,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN SOLR 1 EACH VIAL,14314,CDM,250,RC,781912585,NDC,,,facility,both,1,UN,,106,79.5,,,,,,,,,,Gross Charge Type: Pharmacy
NALBUPHINE 10 MG/ML SOLN,14325,CDM,636,RC,J2300,HCPCS,409146301,NDC,facility,both,10,ME,,36.57,27.43,,,,,,,,,,Gross Charge Type: Pharmacy
NALBUPHINE 20 MG/ML SOLN,14326,CDM,636,RC,J2300,HCPCS,409146501,NDC,facility,both,10,ME,,29.8,22.35,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML SOLN,14380,CDM,636,RC,J2310,HCPCS,67457029202,NDC,facility,both,1,ME,,51.74,38.8,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML SOLN,14380,CDM,636,RC,J2310,HCPCS,409121501,NDC,facility,both,1,ME,,90.2,67.65,,,,,,,,,,Gross Charge Type: Pharmacy
ADAPALENE 0.1 % GEL,1443,CDM,250,RC,MHS1GM,HCPCS,299492030,NDC,facility,both,1,GM,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG TABS,14430,CDM,250,RC,50268059415,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG TABS,14430,CDM,250,RC,50268059415,NDC,,,facility,both,2,UN,,4.28,3.21,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 375 MG TABS,14431,CDM,250,RC,65162018910,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 375 MG TABS,14431,CDM,250,RC,50268059515,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 550 MG TABS,14434,CDM,250,RC,68462017901,NDC,,,facility,both,1,UN,,9.2,6.9,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 550 MG TABS,14434,CDM,250,RC,50228043301,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG/5ML SOLN,14463,CDM,250,RC,MHS1ML,HCPCS,16714067102,NDC,facility,both,1,ML,,2.38,1.79,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5ML OR SOLN,14463,CDM,16714067102,NDC,,,,,facility,both,1,ML,,1.74,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5ML OR SOLN,14463,CDM,16714067102,NDC,,,,,facility,both,1,ML,,10.28,7.71,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG TABS,14506,CDM,250,RC,904629061,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG TABS,14506,CDM,250,RC,904629061,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG TABS,14506,CDM,250,RC,904629061,NDC,,,facility,both,2,UN,,3.92,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG TABS,14506,CDM,250,RC,904629061,NDC,,,facility,both,4,UN,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG TABS,14506,CDM,250,RC,904629061,NDC,,,facility,both,1.5,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG TABS,14506,CDM,250,RC,904629061,NDC,,,facility,both,8,UN,,1.28,0.96,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG TABS,14508,CDM,250,RC,904629161,NDC,,,facility,both,2,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG TABS,14508,CDM,250,RC,904629161,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG TABS,14508,CDM,250,RC,904629161,NDC,,,facility,both,3,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG TABS,14508,CDM,250,RC,904629161,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PRES-FREE) 100 MCG/ML SOLN,14524,CDM,636,RC,J0735,HCPCS,143972401,NDC,facility,both,1,ME,,151.45,113.59,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PRES-FREE) 100 MCG/ML SOLN 10 ML VIAL,14524,CDM,636,RC,J0735,HCPCS,39822200001,NDC,facility,both,1,ME,,39.3,29.48,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PRES-FREE) 100 MCG/ML SOLN 10 ML VIAL,14524,CDM,636,RC,J0735,HCPCS,143972401,NDC,facility,both,1,ME,,151.45,113.59,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PRES-FREE) 100 MCG/ML SOLN 10 ML VIAL,14524,CDM,636,RC,J0735,HCPCS,67457021810,NDC,facility,both,1,ME,,86.2,64.65,,,,,,,,,,Gross Charge Type: Pharmacy
OLOPATADINE 0.1 % SOLN 5 ML BOTTLE,14620,CDM,250,RC,58602000640,NDC,,,facility,both,5,ML,,38.35,28.76,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 25 MG TABS,14668,CDM,250,RC,60687023101,NDC,,,facility,both,4,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 25 MG TABS,14668,CDM,250,RC,60687023101,NDC,,,facility,both,6,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 25 MG TABS,14668,CDM,250,RC,60687023101,NDC,,,facility,both,1.5,UN,,4.42,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 25 MG TABS,14668,CDM,250,RC,60687023101,NDC,,,facility,both,1,UN,,7.74,5.8,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 25 MG TABS,14668,CDM,250,RC,904692461,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 25 MG TABS,14668,CDM,250,RC,60687023101,NDC,,,facility,both,3,UN,,3.37,2.52,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 25 MG TABS,14668,CDM,250,RC,60687023101,NDC,,,facility,both,0.5,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 25 MG TABS,14668,CDM,250,RC,904692461,NDC,,,facility,both,1,UN,,7.13,5.35,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 25 MG TABS,14668,CDM,250,RC,60687023101,NDC,,,facility,both,2,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN 500 MG TABS,14676,CDM,250,RC,93117701,NDC,,,facility,both,2,UN,,5.8,4.35,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN 500 MG TABS,14676,CDM,250,RC,39822031005,NDC,,,facility,both,2,UN,,6.68,5.01,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN 100 MG TABS,14818,CDM,250,RC,80681005700,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN 500 MG TABS,14823,CDM,250,RC,904227260,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG CAPS,14873,CDM,250,RC,904722961,NDC,,,facility,both,2,UN,,5.68,4.26,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG CAPS,14873,CDM,250,RC,69315021101,NDC,,,facility,both,3,UN,,3.73,2.8,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG CAPS,14873,CDM,250,RC,69315021101,NDC,,,facility,both,2,UN,,5.02,3.77,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG CAPS,14873,CDM,250,RC,69315021101,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG CAPS,14873,CDM,250,RC,904722961,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG CAPS,14873,CDM,250,RC,904722961,NDC,,,facility,both,3,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,15010,CDM,68462063945,NDC,,,,,facility,both,1,EA,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SUBL,15010,CDM,250,RC,71041813,NDC,,,facility,both,1,UN,,2.55,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SUBL,15010,CDM,250,RC,J8499W,HCPCS,43598043601,NDC,facility,both,1,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SUBL,15010,CDM,250,RC,58151031094,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SUBL,15010,CDM,250,RC,68462063945,NDC,,,facility,both,25,UN,,0.94,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SUBL,15010,CDM,250,RC,70756001402,NDC,,,facility,both,1,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SUBL,15010,CDM,250,RC,68462063945,NDC,,,facility,both,1,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SUBL,15010,CDM,250,RC,J8499W,HCPCS,68462063945,NDC,facility,both,1,UN,,0.65,0.49,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SUBL,15010,CDM,250,RC,J8499W,HCPCS,71041813,NDC,facility,both,1,UN,,10.65,7.99,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SUBL,15010,CDM,250,RC,68462063945,NDC,,,facility,both,2,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 % OINT,15012,CDM,250,RC,MHS1GM,HCPCS,281032608,NDC,facility,both,1,GM,,22.99,17.24,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML SOLN,15141,CDM,250,RC,MHS1ML,HCPCS,55150022220,NDC,facility,both,1,ML,,3.46,2.6,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML SOLN,15141,CDM,250,RC,MHS1ML,HCPCS,143950610,NDC,facility,both,1,ML,,6.98,5.24,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML SOLN,15141,CDM,250,RC,MHS1ML,HCPCS,72266014601,NDC,facility,both,1,ML,,6.27,4.7,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML SOLN,15141,CDM,250,RC,MHS1ML,HCPCS,55150022110,NDC,facility,both,1,ML,,7.44,5.58,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML SOLN,15141,CDM,250,RC,MHS1ML,HCPCS,409669501,NDC,facility,both,1,ML,,6.97,5.23,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML SOLN,15141,CDM,250,RC,MHS1ML,HCPCS,65219044510,NDC,facility,both,1,ML,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML SOLN,15141,CDM,250,RC,MHS1ML,HCPCS,143950710,NDC,facility,both,1,ML,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML SOLN,15141,CDM,250,RC,MHS1ML,HCPCS,72266014610,NDC,facility,both,1,ML,,9.69,7.27,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG CAPS,15185,CDM,250,RC,51672400105,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG CAPS,15185,CDM,250,RC,51672400105,NDC,,,facility,both,3,UN,,2.63,1.97,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG CAPS,15185,CDM,250,RC,51672400105,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG CAPS,15186,CDM,250,RC,50268060415,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG CAPS,15186,CDM,250,RC,50268060415,NDC,,,facility,both,3,UN,,3.47,2.6,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG CAPS,15186,CDM,250,RC,51672400201,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG CAPS,15186,CDM,250,RC,51672400201,NDC,,,facility,both,2,UN,,3.78,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG CAPS,15186,CDM,250,RC,51672400201,NDC,,,facility,both,3,UN,,2.78,2.09,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG CAPS,15186,CDM,250,RC,50268060415,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG CAPS,15186,CDM,250,RC,50268060415,NDC,,,facility,both,4,UN,,2.81,2.11,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM CREA 30 G TUBE,15381,CDM,250,RC,MHS1GM,HCPCS,45802005911,NDC,facility,both,1,GM,,1.73,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM OINT 15 G TUBE,15382,CDM,250,RC,MHS1G,HCPCS,45802004835,NDC,facility,both,1,GM,,3.39,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML SUSP,15383,CDM,250,RC,MHS1ML,HCPCS,904727670,NDC,facility,both,1,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML SUSP,15383,CDM,250,RC,MHS1ML,HCPCS,121478505,NDC,facility,both,1,ML,,2.01,1.51,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML SUSP,15383,CDM,250,RC,MHS1ML,HCPCS,63739016010,NDC,facility,both,1,ML,,1.04,0.78,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% CREA 15 G TUBE,15393,CDM,250,RC,51672126301,NDC,,,facility,both,15,GR,,71.8,53.85,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% OINT 15 G TUBE,15394,CDM,250,RC,51672127201,NDC,,,facility,both,15,GR,,117.05,87.79,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN SOLR 1 EACH VIAL,1545,CDM,636,RC,J9040,HCPCS,71288010720,NDC,facility,both,15,UN,,54.8,41.1,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN SOLR 1 EACH VIAL,1545,CDM,636,RC,J9040,HCPCS,16714090801,NDC,facility,both,15,UN,,66.18,49.63,,,,,,,,,,Gross Charge Type: Pharmacy
ORA-PLUS LIQD 473 ML BOTTLE,15693,CDM,250,RC,574030316,NDC,,,facility,both,20,ML,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
ORA-PLUS LIQD 473 ML BOTTLE,15693,CDM,250,RC,574030316,NDC,,,facility,both,30,ML,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE 30 MG/ML 30 MG/ML SOLN,15825,CDM,636,RC,J2360,HCPCS,641618210,NDC,facility,both,60,ME,,87.6,65.7,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TABS,15987,CDM,250,RC,60687067001,NDC,,,facility,both,0.5,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TABS,15987,CDM,250,RC,832003889,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TABS,15987,CDM,250,RC,60687067001,NDC,,,facility,both,2,UN,,4.82,3.62,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TABS,15987,CDM,250,RC,904702761,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TABS,15987,CDM,250,RC,60687067001,NDC,,,facility,both,3,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TABS,15987,CDM,250,RC,832003801,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TABS,15987,CDM,250,RC,60687067001,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5-325 MG TABS,15990,CDM,250,RC,406051262,NDC,,,facility,both,0.5,UN,,5.5,4.12,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5-325 MG TABS,15990,CDM,250,RC,406051262,NDC,,,facility,both,3,UN,,2.33,1.75,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5-325 MG TABS,15990,CDM,250,RC,406051262,NDC,,,facility,both,2,UN,,3.2,2.4,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5-325 MG TABS,15990,CDM,250,RC,406051262,NDC,,,facility,both,1,UN,,5.8,4.35,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % SOLN 15 ML BOTTLE,15996,CDM,250,RC,MHS1ML,HCPCS,23900001252,NDC,facility,both,1,ML,,0.68,0.51,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % SOLN 30 ML BOTTLE,15996,CDM,250,RC,J3490,HCPCS,49348002827,NDC,facility,both,1,ML,,0.17,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % SOLN 30 ML BOTTLE,15996,CDM,250,RC,MHS1ML,HCPCS,45802041059,NDC,facility,both,1,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % SOLN 30 ML BOTTLE,15996,CDM,250,RC,J3490,HCPCS,45802041059,NDC,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % SOLN 30 ML BOTTLE,15996,CDM,250,RC,MHS1ML,HCPCS,49348002827,NDC,facility,both,1,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE HCL 0.05 % NA SOLN,15996,CDM,49348002827,NDC,,,,,facility,both,1,ML,,0.26,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE HCL 0.05 % NA SOLN,15996,CDM,45802041059,NDC,,,,,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNITS/ML SOLN,16002,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,both,10,UN,,32.61,24.46,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNITS/ML SOLN 10 ML VIAL,16002,CDM,636,RC,J2590,HCPCS,42023011602,NDC,facility,both,10,UN,,18.33,13.75,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (OYSTER SHELL) 500 MG TABS,16023,CDM,250,RC,904188361,NDC,,,facility,both,2,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (OYSTER SHELL) 500 MG TABS,16023,CDM,250,RC,904188361,NDC,,,facility,both,2.5,UN,,2.17,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (OYSTER SHELL) 500 MG TABS,16023,CDM,250,RC,20555000301,NDC,,,facility,both,2,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (OYSTER SHELL) 500 MG TABS,16023,CDM,250,RC,904188361,NDC,,,facility,both,1,UN,,6.18,4.64,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (OYSTER SHELL) 500 MG TABS,16023,CDM,250,RC,904188361,NDC,,,facility,both,3,UN,,2.2,1.65,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (OYSTER SHELL) 500 MG TABS,16023,CDM,250,RC,904188361,NDC,,,facility,both,0.5,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (OYSTER SHELL) 500 MG TABS,16023,CDM,250,RC,20555000301,NDC,,,facility,both,3,UN,,2.1,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (OYSTER SHELL) 500 MG TABS,16023,CDM,250,RC,20555000301,NDC,,,facility,both,1,UN,,6.02,4.51,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (OYSTER SHELL) 500 MG TABS,16023,CDM,250,RC,20555000301,NDC,,,facility,both,2.5,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML SOLN,16256,CDM,636,RC,J2440,HCPCS,517400225,NDC,facility,both,2,ML,,64.56,48.42,,,,,,,,,,Gross Charge Type: Pharmacy
COPPER INTRAUTERINE DEVICE IUD,16305,CDM,636,RC,J7300,HCPCS,59365512801,NDC,facility,both,1,EA,,1283.1,962.32,,,,,,,,,,Gross Charge Type: Pharmacy
PARAGARD INTRAUTERINE COPPER IU IUD,16305,CDM,59365512801,NDC,,,,,facility,both,1,EA,,1442.78,1082.08,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1 MG/ML SOLN,164798,CDM,636,RC,J2710,HCPCS,641614910,NDC,facility,both,0.5,ME,,7.82,5.87,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1 MG/ML SOLN,164798,CDM,636,RC,J2710,HCPCS,43598052911,NDC,facility,both,0.5,ME,,11.72,8.79,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM SOLR 1 EACH VIAL,16495,CDM,636,RC,J2540,HCPCS,44567031110,NDC,facility,both,600000,UN,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM SOLR 1 EACH VIAL,16495,CDM,636,RC,J2540,HCPCS,49052083,NDC,facility,both,600000,UN,,6.41,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM SOLR 1 EACH VIAL,16495,CDM,636,RC,J2540,HCPCS,49052022,NDC,facility,both,600000,UN,,6.29,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG/5ML SOLR,16512,CDM,250,RC,MHS5ml,HCPCS,93412773,NDC,facility,both,5,ML,,3.76,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 500 MG TABS,16514,CDM,250,RC,16714023501,NDC,,,facility,both,1,UN,,7.85,5.89,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRIC ACID 135 MG CPDR,165149,CDM,250,RC,115155510,NDC,,,facility,both,1,UN,,9.68,7.26,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,50111078710,NDC,,,facility,both,1,UN,,7.49,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,904735006,NDC,,,facility,both,1,UN,,8.66,6.5,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,59762219807,NDC,,,facility,both,4,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,60687074201,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,60687074201,NDC,,,facility,both,3,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,904735006,NDC,,,facility,both,4,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,59762219807,NDC,,,facility,both,2,UN,,6.82,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,59762219807,NDC,,,facility,both,1,UN,,10.41,7.81,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,50111078710,NDC,,,facility,both,4,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,65862064163,NDC,,,facility,both,2,UN,,5.42,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,50111078710,NDC,,,facility,both,2,UN,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,904735006,NDC,,,facility,both,2,UN,,5.12,3.84,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,65862064163,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,60687074201,NDC,,,facility,both,4,UN,,4.02,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,16518,CDM,250,RC,60687074201,NDC,,,facility,both,2,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB 12.5 MG/ML SOLN 4 ML VIAL,165245,CDM,636,RC,J1602,HCPCS,57894035001,NDC,facility,both,1,ME,,94.67,71.01,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE 50 MG/ML SOLN,165267,CDM,636,RC,J1439,HCPCS,517065001,NDC,facility,both,1,ME,,2.98,2.23,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE 50 MG/ML SOLN 15 ML VIAL,165267,CDM,636,RC,J1439,HCPCS,517065001,NDC,facility,both,1,ME,,2.98,2.24,,,,,,,,,,Gross Charge Type: Pharmacy
DOLUTEGRAVIR 50 MG TABS,165614,CDM,250,RC,49702022813,NDC,,,facility,both,1,UN,,119.1,89.32,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.75 % SOLN,165849,CDM,250,RC,MHS1ML,HCPCS,409158210,NDC,facility,both,0.5,ME,,27.75,20.81,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.75 % SOLN,165849,CDM,250,RC,J0665,HCPCS,409158210,NDC,facility,both,0.5,ME,,1.57,1.18,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.75 % SOLN,165849,CDM,636,RC,J0665,HCPCS,409158210,NDC,facility,both,0.5,ME,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML SOLN 25 ML VIAL,165856,CDM,636,RC,J9181,HCPCS,16729011408,NDC,facility,both,10,ME,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML SOLN 5 ML VIAL,165856,CDM,636,RC,J9181,HCPCS,143951001,NDC,facility,both,10,ME,,2.03,1.52,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML SOLN 50 ML VIAL,165856,CDM,636,RC,J9181,HCPCS,143951201,NDC,facility,both,10,ME,,3.06,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML SOLN 50 ML VIAL,165856,CDM,636,RC,J9181,HCPCS,16729011411,NDC,facility,both,10,ME,,1.67,1.26,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 10 MG T12A,165864,CDM,250,RC,59011041020,NDC,,,facility,both,4,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 10 MG T12A,165864,CDM,250,RC,59011041020,NDC,,,facility,both,1,UN,,12.6,9.45,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 10 MG T12A,165864,CDM,250,RC,59011041010,NDC,,,facility,both,2,UN,,10.75,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 10 MG T12A,165864,CDM,250,RC,59011041010,NDC,,,facility,both,4,UN,,9.34,7,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 10 MG T12A,165864,CDM,250,RC,59011041010,NDC,,,facility,both,1,UN,,13.35,10.01,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 10 MG T12A,165864,CDM,250,RC,59011041020,NDC,,,facility,both,3,UN,,9.32,6.99,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 10 MG T12A,165864,CDM,250,RC,59011041020,NDC,,,facility,both,2,UN,,10.2,7.65,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 15 MG T12A,165866,CDM,250,RC,59011041510,NDC,,,facility,both,2,UN,,13.5,10.12,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 15 MG T12A,165866,CDM,250,RC,59011041520,NDC,,,facility,both,2,UN,,13.78,10.33,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 15 MG T12A,165866,CDM,250,RC,59011041520,NDC,,,facility,both,1,UN,,16.35,12.26,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 15 MG T12A,165866,CDM,250,RC,59011041510,NDC,,,facility,both,1,UN,,16.1,12.08,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 20 MG T12A,165867,CDM,250,RC,59011042020,NDC,,,facility,both,3,UN,,15.58,11.69,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 20 MG T12A,165867,CDM,250,RC,59011042020,NDC,,,facility,both,1,UN,,19.04,14.28,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 20 MG T12A,165867,CDM,250,RC,59011042020,NDC,,,facility,both,2,UN,,16.6,12.45,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 40 MG T12A,165869,CDM,250,RC,59011044020,NDC,,,facility,both,1,UN,,29.3,21.98,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 2.5-108 MG/5ML SOLN,165894,CDM,250,RC,121477240,NDC,,,facility,both,12.3,ML,,11.32,8.49,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 2.5-108 MG/5ML SOLN,165894,CDM,250,RC,121477240,NDC,,,facility,both,20,ML,,12.82,9.62,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 2.5-108 MG/5ML SOLN,165894,CDM,250,RC,121477240,NDC,,,facility,both,8.1,ML,,12.18,9.13,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 2.5-108 MG/5ML SOLN,165894,CDM,250,RC,121477240,NDC,,,facility,both,10,ML,,14.38,10.78,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 2.5-108 MG/5ML SOLN,165894,CDM,250,RC,121477240,NDC,,,facility,both,5,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 2.5-108 MG/5ML SOLN,165894,CDM,250,RC,121477240,NDC,,,facility,both,15,ML,,13.35,10.01,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 200 MCG/2ML SOLN,166048,CDM,250,RC,MHS1ML,HCPCS,409163802,NDC,facility,both,1,ML,,78.42,58.82,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 200 MCG/2ML SOLN,166048,CDM,250,RC,MHS1ML,HCPCS,42023014625,NDC,facility,both,1,ML,,23.99,17.99,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 200 MCG/2ML SOLN,166048,CDM,250,RC,MHS1ML,HCPCS,55150020902,NDC,facility,both,1,ML,,15.25,11.44,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,166048,CDM,250,RC,MHS1ML,HCPCS,16729023993,NDC,facility,both,1,ML,,21.64,16.23,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,166048,CDM,250,RC,MHS1ML,HCPCS,55150020902,NDC,facility,both,1,ML,,11.5,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,166048,CDM,250,RC,MHS1ML,HCPCS,71288050503,NDC,facility,both,1,ML,,19.36,14.52,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,166048,CDM,250,RC,MHS1ML,HCPCS,42023014625,NDC,facility,both,1,ML,,14.94,11.2,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 200 MCG/2ML SOLN 2 ML VIAL,166048,CDM,250,RC,MHS1ML,HCPCS,66794023042,NDC,facility,both,1,ML,,10.28,7.71,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG/VIAL SOLR 1 EACH VIAL,166069,CDM,636,RC,J9041,HCPCS,71288011810,NDC,facility,both,0.1,ME,,4.5,3.37,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG/VIAL SOLR 1 EACH VIAL,166069,CDM,636,RC,J9044,HCPCS,71288011810,NDC,facility,both,0.1,ME,,4.18,3.14,,,,,,,,,,Gross Charge Type: Pharmacy
VORTIOXETINE 5 MG TABS,166275,CDM,250,RC,64764072030,NDC,,,facility,both,2,UN,,29.97,22.47,,,,,,,,,,Gross Charge Type: Pharmacy
VORTIOXETINE 5 MG TABS,166275,CDM,250,RC,64764072030,NDC,,,facility,both,3,UN,,26.62,19.96,,,,,,,,,,Gross Charge Type: Pharmacy
VORTIOXETINE 5 MG TABS,166275,CDM,250,RC,64764072030,NDC,,,facility,both,1,UN,,33.65,25.24,,,,,,,,,,Gross Charge Type: Pharmacy
VORTIOXETINE 5 MG TABS,166275,CDM,250,RC,64764072030,NDC,,,facility,both,4,UN,,26.12,19.59,,,,,,,,,,Gross Charge Type: Pharmacy
VORTIOXETINE 20 MG TABS,166277,CDM,250,RC,64764075030,NDC,,,facility,both,1,UN,,34.9,26.18,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE-MINERAL OIL-PETROLATUM 0.25-14-74.9 % OINT 57 G TUBE,166438,CDM,250,RC,573287194,NDC,,,facility,both,57,GR,,40.25,30.19,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE-MINERAL OIL-PETROLATUM 0.25-14-74.9 % OINT 57 G TUBE,166438,CDM,250,RC,45802018816,NDC,,,facility,both,57,GR,,25.7,19.28,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 25 MG/ML SOLN 40 ML VIAL,166622,CDM,636,RC,J9301,HCPCS,50242007001,NDC,facility,both,10,ME,,222.16,166.62,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE 4 MG TABS,16666,CDM,250,RC,68084060201,NDC,,,facility,both,2,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE 4 MG TABS,16666,CDM,250,RC,68084060201,NDC,,,facility,both,1,UN,,11.1,8.32,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE 4 MG TABS,16666,CDM,250,RC,68084060201,NDC,,,facility,both,1.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE 4 MG TABS,16666,CDM,250,RC,23155080001,NDC,,,facility,both,2,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERATE MEGLUMINE 5 MMOL/10ML SOLN,166886,CDM,636,RC,A9575,HCPCS,67684200101,NDC,facility,both,0.1,ML,,0.89,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERATE MEGLUMINE 10 MMOL/20ML SOLN,166889,CDM,636,RC,A9575,HCPCS,67684200103,NDC,facility,both,0.1,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN 5 MG TABS,167220,CDM,250,RC,310620530,NDC,,,facility,both,2,UN,,28.92,21.69,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN 5 MG TABS,167220,CDM,250,RC,310620530,NDC,,,facility,both,1,UN,,34.2,25.65,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN 10 MG TABS,167221,CDM,250,RC,310621030,NDC,,,facility,both,1,UN,,34.2,25.65,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN 10 MG TABS,167221,CDM,250,RC,310621030,NDC,,,facility,both,0.5,UN,,21.9,16.42,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 55 MCG/ACTUATION AERO,167396,CDM,250,RC,41167580005,NDC,,,facility,both,16.9,ML,,27.7,20.78,,,,,,,,,,Gross Charge Type: Pharmacy
ESLICARBAZEPINE ACETATE 800 MG TABS,167409,CDM,250,RC,63402020830,NDC,,,facility,both,0.5,UN,,41.08,30.81,,,,,,,,,,Gross Charge Type: Pharmacy
ESLICARBAZEPINE ACETATE 800 MG TABS,167409,CDM,250,RC,63402020830,NDC,,,facility,both,1,UN,,72.21,54.15,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML SOLN 5 ML VIAL,167699,CDM,636,RC,J9181,HCPCS,16729011431,NDC,facility,both,10,ME,,2.28,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 16 MG/2ML IX SOSY,167705,CDM,58468009001,NDC,,,,,facility,both,1,ML,,38.31,28.74,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (HYLAN) 8 MG/ML SOSY,167705,CDM,636,RC,J7325,HCPCS,58468009001,NDC,facility,both,1,ME,,23.77,17.83,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 48 MG/6ML IX SOSY,167706,CDM,58468009003,NDC,,,,,facility,both,1,ML,,40.21,30.16,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE 8 MG/ML SOSY,167706,CDM,636,RC,J7325,HCPCS,58468009003,NDC,facility,both,1,ME,,22.39,16.8,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASPART 100 UNIT/ML SOPN,167728,CDM,636,RC,J1815,HCPCS,169633910,NDC,facility,both,5,UN,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG/ML SOLN,167738,CDM,250,RC,641602225,NDC,,,facility,both,2,ML,,31.5,23.62,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SOPN,167740,CDM,637,RC,169643210,NDC,,,facility,both,0.5,ML,,64.25,48.19,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,167741,CDM,636,RC,J1100,HCPCS,67457042254,NDC,facility,both,1,ME,,6.42,4.82,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,167741,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,both,1,ME,,4.56,3.42,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,167741,CDM,636,RC,J1100,HCPCS,72572012001,NDC,facility,both,1,ME,,2.98,2.24,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,167741,CDM,636,RC,J1100,HCPCS,67457042312,NDC,facility,both,1,ME,,2.13,1.6,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL,167741,CDM,636,RC,J1100,HCPCS,67457042312,NDC,facility,both,1,ME,,3.26,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL,167741,CDM,636,RC,J1100,HCPCS,72572012001,NDC,facility,both,1,ME,,4.01,3,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN 5 ML VIAL,167741,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,both,1,ME,,4.17,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN 5 ML VIAL,167741,CDM,636,RC,J1100,HCPCS,67457042254,NDC,facility,both,1,ME,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN,167741,CDM,67457042254,NDC,,,,,facility,both,1,ML,,7.21,5.41,,,,,,,,,,Gross Charge Type: Pharmacy
LIRAGLUTIDE 18 MG/3ML SOPN 3 ML PEN,167747,CDM,250,RC,169406012,NDC,,,facility,both,3,ML,,1030.95,773.21,,,,,,,,,,Gross Charge Type: Pharmacy
LIRAGLUTIDE 18 MG/3ML SOPN 3 ML PEN,167747,CDM,250,RC,169406013,NDC,,,facility,both,3,ML,,1030.95,773.21,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML SOAJ,167755,CDM,636,RC,J0171,HCPCS,49502050001,NDC,facility,both,0.1,ME,,303.63,227.72,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML SOAJ,167755,CDM,636,RC,J0171,HCPCS,49502010202,NDC,facility,both,0.1,ME,,140.63,105.47,,,,,,,,,,Gross Charge Type: Pharmacy
"PROTHROMBIN COMPLEX CONCENTRATE, 4 FACTOR 1000 UNITS KIT",167901,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,both,1,UN,,4.96,3.72,,,,,,,,,,Gross Charge Type: Pharmacy
"PROTHROMBIN COMPLEX CONCENTRATE, 4 FACTOR 1000 UNITS KIT 1,000 UNITS BOX",167901,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,both,1,UN,,4.96,3.72,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG TABS,16798,CDM,250,RC,51293081001,NDC,,,facility,both,1,UN,,8.05,6.04,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG TABS,16798,CDM,250,RC,65162068110,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG TABS,16798,CDM,250,RC,51293081001,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG TABS,16798,CDM,250,RC,65162068110,NDC,,,facility,both,1,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 200 MG TABS,16799,CDM,250,RC,51293081101,NDC,,,facility,both,1,UN,,13.15,9.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 200 MG TABS,16799,CDM,250,RC,65162068210,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 200 MG TABS,16799,CDM,250,RC,65162068210,NDC,,,facility,both,0.5,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG KIT,16834,CDM,636,RC,J1950,HCPCS,74366303,NDC,facility,both,3.75,ME,,4497.59,3373.19,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML SOLN,168438,CDM,636,RC,J2270,HCPCS,63323045201,NDC,facility,both,10,ME,,36.58,27.43,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML SOLN,168438,CDM,636,RC,63323045201,NDC,,,facility,both,10,ME,,37.05,27.79,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML SOLN,168438,CDM,636,RC,J2272,HCPCS,63323045201,NDC,facility,both,10,ME,,36.86,27.64,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML SOLN,168438,CDM,636,RC,J2251,HCPCS,63323045201,NDC,facility,both,10,ME,,18.52,13.89,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS,16846,CDM,250,RC,13517069401,NDC,,,facility,both,1,UN,,2.63,1.97,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS,16846,CDM,250,RC,143145801,NDC,,,facility,both,1.162,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS,16846,CDM,250,RC,143145801,NDC,,,facility,both,0.757,UN,,1,0.75,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS,16846,CDM,250,RC,13517069401,NDC,,,facility,both,0.757,UN,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS,16846,CDM,250,RC,143145801,NDC,,,facility,both,1.5,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS,16846,CDM,250,RC,143145801,NDC,,,facility,both,1,UN,,2.7,2.03,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS,16846,CDM,250,RC,13517069401,NDC,,,facility,both,1.581,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS,16846,CDM,250,RC,13517069401,NDC,,,facility,both,1.5,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS 100 EACH BOTTLE,16846,CDM,250,RC,143145801,NDC,,,facility,both,1,UN,,1.3,0.98,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 100 MG TABS 100 EACH BOTTLE,16846,CDM,250,RC,13517069401,NDC,,,facility,both,1,UN,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,0.5,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,5,UN,,1.75,1.31,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,5.0864,UN,,1.47,1.1,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,63739029410,NDC,,,facility,both,1,UN,,5.69,4.27,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,4.0864,UN,,1.62,1.22,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,3,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,63739029410,NDC,,,facility,both,3,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,63739029410,NDC,,,facility,both,5,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,4,UN,,2.01,1.51,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,1.7932,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,1,UN,,5.72,4.29,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,63739029410,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,1.25,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,904657561,NDC,,,facility,both,4.5,UN,,1.68,1.26,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS,16850,CDM,250,RC,63739029410,NDC,,,facility,both,4,UN,,2.66,2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 32.4 MG TABS 100 EACH BOX,16850,CDM,250,RC,904657561,NDC,,,facility,both,1,UN,,4.18,3.14,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 130 MG/ML SOLN,16856,CDM,636,RC,J2560,HCPCS,641047725,NDC,facility,both,120,ME,,209.11,156.83,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 130 MG/ML SOLN,16856,CDM,636,RC,J2560,HCPCS,42494041601,NDC,facility,both,120,ME,,107.64,80.73,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 130 MG/ML SOLN 1 ML VIAL,16856,CDM,636,RC,J2560,HCPCS,641047725,NDC,facility,both,120,ME,,139.02,104.26,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 130 MG/ML SOLN 1 ML VIAL,16856,CDM,636,RC,J2560,HCPCS,42494041601,NDC,facility,both,120,ME,,66.39,49.79,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONAN 88 MG/4ML IX SOSY,168562,CDM,59676082001,NDC,,,,,facility,both,88,ML,,3235.05,2426.29,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONAN 88 MG/4ML SOSY,168562,CDM,636,RC,J7327,HCPCS,59676082001,NDC,facility,both,88,ME,,3143.29,2357.47,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML SOLN 10 ML VIAL,168580,CDM,636,RC,J9308,HCPCS,2766901,NDC,facility,both,5,ME,,160.59,120.44,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML SOLN 50 ML VIAL,168580,CDM,636,RC,J9308,HCPCS,2767801,NDC,facility,both,5,ME,,184.02,138.01,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 65 MG/ML SOLN,16859,CDM,636,RC,J2560,HCPCS,641047625,NDC,facility,both,120,ME,,106.53,79.9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 65 MG/ML SOLN 1 ML VIAL,16859,CDM,636,RC,J2560,HCPCS,641047625,NDC,facility,both,120,ME,,104.7,78.52,,,,,,,,,,Gross Charge Type: Pharmacy
SILTUXIMAB 20 MG/ML SOLR 1 EACH VIAL,168613,CDM,636,RC,J2860,HCPCS,73090042001,NDC,facility,both,10,ME,,354.59,265.95,,,,,,,,,,Gross Charge Type: Pharmacy
SILTUXIMAB 20 MG/ML SOLR 1 EACH VIAL,168614,CDM,636,RC,J2860,HCPCS,73090042101,NDC,facility,both,10,ME,,353.95,265.46,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 2.5 MG TABS,16874,CDM,250,RC,60505311000,NDC,,,facility,both,4,UN,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 2.5 MG TABS,16874,CDM,250,RC,60505311000,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 2.5 MG TABS,16874,CDM,250,RC,60505311000,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 2.5 MG TABS,16874,CDM,250,RC,60505311000,NDC,,,facility,both,2,UN,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 2.5 MG TABS,16874,CDM,250,RC,60505311000,NDC,,,facility,both,3,UN,,2.97,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.25 % SOLN,16901,CDM,250,RC,MHS1ML,HCPCS,225080047,NDC,facility,both,1,ML,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 % SOLN 15 ML BOTTLE,16903,CDM,250,RC,MHS1ML,HCPCS,225081047,NDC,facility,both,1,ML,,0.7,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 2.5 % SOLN 15 ML BOTTLE,16907,CDM,250,RC,70756064935,NDC,,,facility,both,15,ML,,137.4,103.05,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 100 MG CAPS,16942,CDM,250,RC,71036924,NDC,,,facility,both,2,UN,,6.82,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 100 MG CAPS,16942,CDM,250,RC,71036924,NDC,,,facility,both,3,UN,,5.43,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 100 MG CAPS,16942,CDM,250,RC,71036940,NDC,,,facility,both,1,UN,,11.1,8.32,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 100 MG CAPS,16942,CDM,250,RC,71036924,NDC,,,facility,both,0.1,UN,,0.9,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 100 MG CAPS,16942,CDM,250,RC,71036924,NDC,,,facility,both,1,UN,,9.44,7.08,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TBCR,169500,CDM,250,RC,68084028101,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25-100 MG TBCR,169500,CDM,250,RC,68084028101,NDC,,,facility,both,2,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
VEDOLIZUMAB 300 MG SOLR 1 EACH VIAL,169521,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,both,1,ME,,68.31,51.23,,,,,,,,,,Gross Charge Type: Pharmacy
DALBAVANCIN 500 MG SOLR 1 EACH VIAL,169624,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,both,5,ME,,39.98,29.98,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % SUPP,169693,CDM,250,RC,536118612,NDC,,,facility,both,1,UN,,20.35,15.26,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % SUPP,169693,CDM,250,RC,573288320,NDC,,,facility,both,1,UN,,21.3,15.98,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 50 MG CAPS,169745,CDM,636,RC,J8530,HCPCS,54038325,NDC,facility,both,25,ME,,11.02,8.26,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 1 MG/ML SOLN,169759,CDM,250,RC,MHS1ML,HCPCS,51672407008,NDC,facility,both,1,ML,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 10 MG TABS,170179,CDM,250,RC,597015230,NDC,,,facility,both,0.5,UN,,13.05,9.79,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 10 MG TABS,170179,CDM,250,RC,597015290,NDC,,,facility,both,1.5,UN,,14.98,11.23,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 10 MG TABS,170179,CDM,250,RC,597015230,NDC,,,facility,both,1,UN,,35.25,26.44,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 10 MG TABS,170179,CDM,250,RC,597015290,NDC,,,facility,both,2.5,UN,,20.15,15.11,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 10 MG TABS,170179,CDM,250,RC,597015237,NDC,,,facility,both,2,UN,,29.95,22.46,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 10 MG TABS,170179,CDM,250,RC,597015237,NDC,,,facility,both,0.5,UN,,21.92,16.44,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 10 MG TABS,170179,CDM,250,RC,597015237,NDC,,,facility,both,2.5,UN,,22.83,17.12,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 10 MG TABS,170179,CDM,250,RC,597015290,NDC,,,facility,both,1,UN,,30.55,22.91,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 10 MG TABS,170179,CDM,250,RC,597015237,NDC,,,facility,both,1,UN,,33.8,25.35,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 2 % SOLN 15 ML BOTTLE,17018,CDM,250,RC,61314020415,NDC,,,facility,both,15,ML,,148.25,111.19,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 25 MG TABS,170181,CDM,250,RC,597015337,NDC,,,facility,both,0.5,UN,,21.76,16.32,,,,,,,,,,Gross Charge Type: Pharmacy
EMPAGLIFLOZIN 25 MG TABS,170181,CDM,250,RC,597015337,NDC,,,facility,both,1,UN,,33.13,24.85,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONAN 30 MG/2ML IX SOSY,170410,CDM,59676036001,NDC,,,,,facility,both,30,ML,,907.02,680.26,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONAN 30 MG/2ML SOSY,170410,CDM,636,RC,J7324,HCPCS,59676036001,NDC,facility,both,30,ME,,1012.52,759.39,,,,,,,,,,Gross Charge Type: Pharmacy
CROSS-LINKED HYALURONATE 30 MG/3ML PRSY,170416,CDM,636,RC,J7326,HCPCS,50016095711,NDC,facility,both,30,ME,,2300,1725,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,170418,CDM,409656201,NDC,,,,,facility,both,1,ML,,0.31,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,170418,CDM,9041701,NDC,,,,,facility,both,1,ML,,0.3,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,170418,CDM,574082001,NDC,,,,,facility,both,1,ML,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,170418,CDM,143965901,NDC,,,,,facility,both,1,ML,,0.33,0.25,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML SOLN,170418,CDM,636,RC,J1071,HCPCS,574082001,NDC,facility,both,1,ME,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML SOLN,170418,CDM,636,RC,J1071,HCPCS,409656201,NDC,facility,both,1,ME,,0.26,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML SOLN,170418,CDM,636,RC,J1071,HCPCS,9041701,NDC,facility,both,1,ME,,0.13,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML SOLN,170418,CDM,636,RC,J1071,HCPCS,143965901,NDC,facility,both,1,ME,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 8 MEQ/5 ML SOLN,170424,CDM,250,RC,72888017246,NDC,,,facility,both,5,ML,,10.65,7.99,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 20 MG/2ML IX SOSY,170441,CDM,55566410000,NDC,,,,,facility,both,20,ML,,485.43,364.07,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 20 MG/2ML IX SOSY,170441,CDM,55566410001,NDC,,,,,facility,both,20,ML,,421.8,316.35,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 20 MG/2ML IX SOSY,170441,CDM,55566410001,NDC,,,,,facility,both,20,ML,,62,46.5,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE 20 MG/2ML SOSY,170441,CDM,636,RC,J7323,HCPCS,55566410001,NDC,facility,both,20,ME,,285.52,214.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE 20 MG/2ML SOSY,170441,CDM,636,RC,J7323,HCPCS,55566410000,NDC,facility,both,20,ME,,300,225,,,,,,,,,,Gross Charge Type: Pharmacy
PINDOLOL 5 MG TABS,17047,CDM,250,RC,76385013101,NDC,,,facility,both,2,UN,,5.88,4.41,,,,,,,,,,Gross Charge Type: Pharmacy
PINDOLOL 5 MG TABS,17047,CDM,250,RC,76385013101,NDC,,,facility,both,1,UN,,9.75,7.31,,,,,,,,,,Gross Charge Type: Pharmacy
PIROXICAM 10 MG CAPS,17071,CDM,250,RC,42571017601,NDC,,,facility,both,2,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG CAPS,170925,CDM,250,RC,70700016201,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG CAPS,170925,CDM,250,RC,16714015701,NDC,,,facility,both,4,UN,,2.99,2.24,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG CAPS,170925,CDM,250,RC,16714015701,NDC,,,facility,both,2,UN,,4.92,3.69,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG CAPS,170925,CDM,250,RC,70700016201,NDC,,,facility,both,2,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG CAPS,170925,CDM,250,RC,16714015701,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM 2.5 MCG/ACT AERS 4 G INHALER,170927,CDM,250,RC,597010061,NDC,,,facility,both,4,GR,,649.1,486.82,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM 2.5 MCG/ACT AERS 4 G INHALER,170927,CDM,250,RC,597010051,NDC,,,facility,both,4,GR,,73.9,55.42,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.035,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.085,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.0004,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.015,ML,,25.35,19.01,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.125,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.02,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.009,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.045,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.25,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.032,ML,,1.61,1.21,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.07,ML,,0.76,0.57,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.22,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.09,ML,,0.67,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.13,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.165,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.005,ML,,25.15,18.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.095,ML,,0.57,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.12,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.16,ML,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.15,ML,,28.4,21.3,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.18,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,72485050501,NDC,facility,both,5,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.06,ML,,0.91,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.035,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.26,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.01,ML,,25.25,18.94,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.23,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.185,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,5,ML,,13.88,10.41,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.05,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.12,ML,,0.46,0.35,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.17,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.35,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.02,ML,,25.5,19.12,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.48,ML,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.055,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.025,ML,,25.6,19.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,5,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.015,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.027,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.24,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2372,HCPCS,781345895,NDC,facility,both,0.03,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.09,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.2,ML,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.28,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,10,ML,,0.01,0.01,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.22,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.12,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.1,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.08,ML,,26.85,20.14,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.02,ML,,2.54,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.016,ML,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.024,ML,,2.13,1.6,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.085,ML,,26.95,20.21,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.08,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.005,ML,,8.38,6.29,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.095,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.21,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.13,ML,,27.95,20.96,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.1,ML,,27.3,20.48,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.15,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.04,ML,,25.95,19.46,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.11,ML,,0.5,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.08,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.14,ML,,28.2,21.15,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.09,ML,,27.05,20.29,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.23,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.16,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.11,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.055,ML,,26.25,19.69,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.04,ML,,1.37,1.03,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.21,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.01,ML,,4.98,3.74,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.004,ML,,12.55,9.41,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.02,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.115,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.155,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.05,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.15,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.26,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.945,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.005,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.2,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.105,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.05,ML,,26.15,19.61,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.19,ML,,0.31,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.055,ML,,0.94,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.005,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.17,ML,,0.34,0.25,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.025,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.002,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.15,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.27,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.06,ML,,26.4,19.8,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.045,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.06,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.03,ML,,25.7,19.28,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.3,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.14,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.03,ML,,1.73,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.155,ML,,0.37,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.2,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.065,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.075,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.08,ML,,0.67,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.025,ML,,2.1,1.57,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.01,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.01,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.07,ML,,26.6,19.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.026,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.18,ML,,29.1,21.82,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.49,ML,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.03,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.04,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.07,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.14,ML,,0.53,0.4,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.17,ML,,28.85,21.64,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.135,ML,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.18,ML,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.045,ML,,26.05,19.54,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.05,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,641614225,NDC,facility,both,0.16,ML,,28.65,21.49,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.015,ML,,3.17,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.13,ML,,0.43,0.32,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.1,ML,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.04,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.24,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.035,ML,,1.77,1.33,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.19,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.1,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,10,ML,,10.77,8.08,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.07,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.03,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.004,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,641614225,NDC,facility,both,0.065,ML,,0.8,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,0.06,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.13,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN 1 ML VIAL,170935,CDM,636,RC,J2371,HCPCS,63323075101,NDC,facility,both,0.03,ML,,1.69,1.26,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN 1 ML VIAL,170935,CDM,636,RC,J2371,HCPCS,63323075101,NDC,facility,both,4,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL,170935,CDM,636,RC,J2371,HCPCS,72485050501,NDC,facility,both,5,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,10,ML,,0.01,0.01,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,10,ML,,10.77,8.08,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL,170935,CDM,636,RC,J2371,HCPCS,72485050501,NDC,facility,both,10,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL,170935,CDM,636,RC,J2370,HCPCS,781345895,NDC,facility,both,5,ML,,13.93,10.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.5,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL,170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,5,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"PR INJECTION, PHENYLEPHRINE HYDROCHLORIDE, 20 MICROGRAMS",170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,0.04,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
"PR INJECTION, PHENYLEPHRINE HYDROCHLORIDE, 20 MICROGRAMS",170935,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,5,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNITS/ML SOLN 1 ML VIAL,171291,CDM,636,RC,J2598,HCPCS,63323093000,NDC,facility,both,1,UN,,4.14,3.1,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNITS/ML SOLN 1 ML VIAL,171291,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,both,1,UN,,12.68,9.51,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNITS/ML SOLN 1 ML VIAL,171291,CDM,636,RC,J2598,HCPCS,548970100,NDC,facility,both,1,UN,,8.83,6.62,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNITS/ML SOLN 1 ML VIAL,171291,CDM,250,RC,J2598,HCPCS,42023016425,NDC,facility,both,1,UN,,12.68,9.51,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNITS/ML SOLN 1 ML VIAL,171291,CDM,250,RC,42023016425,NDC,,,facility,both,1,UN,,613.7,460.28,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 12.5 MCG/ML SOLR 1 EACH VIAL,171511,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,both,6,UN,,365.74,274.3,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 12.5 MCG/ML SOLR 1 EACH VIAL,171511,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,both,0.485714286,UN,,467.67,350.75,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 12.5 MCG/ML SOLR 1 EACH VIAL,171511,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,both,0.514285714,UN,,462.59,346.94,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 12.5 MCG/ML SOLR 1 EACH VIAL,171511,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,both,0.742857143,UN,,427.07,320.3,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 12.5 MCG/ML SOLR 1 EACH VIAL,171511,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,both,0.257142857,UN,,512.58,384.44,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 12.5 MCG/ML SOLR 1 EACH VIAL,171511,CDM,636,RC,J9039,HCPCS,55513016001,NDC,facility,both,1.142857143,UN,,397.19,297.89,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G SOLR 1 EACH VIAL,171564,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,both,75,ME,,19.86,14.9,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 10 MG/ML SOLN 4 ML VIAL,171566,CDM,636,RC,J9299,HCPCS,3377211,NDC,facility,both,1,ME,,83.06,62.3,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 10 MG/ML SOLN 10 ML VIAL,171567,CDM,636,RC,J9299,HCPCS,3377412,NDC,facility,both,1,ME,,86.35,64.76,,,,,,,,,,Gross Charge Type: Pharmacy
MENINGOCOCCAL B RECOMB VACCINE SUSY,171719,CDM,636,RC,90620,HCPCS,58160097620,NDC,facility,both,0.5,ML,,120.85,90.64,,,,,,,,,,Gross Charge Type: Pharmacy
EDOXABAN 30 MG TABS,171765,CDM,250,RC,65597020230,NDC,,,facility,both,2,UN,,26.85,20.14,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 10 MG CAPS,171786,CDM,250,RC,59417010110,NDC,,,facility,both,2,UN,,26.72,20.04,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 10 MG CAPS,171786,CDM,250,RC,59417010110,NDC,,,facility,both,1,UN,,29.42,22.07,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 10 MG CAPS,171786,CDM,250,RC,60505473901,NDC,,,facility,both,1,UN,,23.23,17.42,,,,,,,,,,Gross Charge Type: Pharmacy
LISDEXAMFETAMINE 10 MG CAPS,171786,CDM,250,RC,60505473901,NDC,,,facility,both,2,UN,,23.11,17.33,,,,,,,,,,Gross Charge Type: Pharmacy
PEMBROLIZUMAB 25 MG/ML SOLN 4 ML VIAL,171822,CDM,636,RC,J9271,HCPCS,6302604,NDC,facility,both,1,ME,,147.56,110.67,,,,,,,,,,Gross Charge Type: Pharmacy
PEMBROLIZUMAB 25 MG/ML SOLN 4 ML VIAL,171822,CDM,636,RC,J9271,HCPCS,6302602,NDC,facility,both,1,ME,,147.44,110.58,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSAMINE-CHONDROITIN 500-400 MG CAPS,17187,CDM,250,RC,80681011701,NDC,,,facility,both,2,UN,,3.85,2.89,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSAMINE-CHONDROITIN 500-400 MG CAPS,17187,CDM,250,RC,80681011701,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Newborn Level 2,1720000001,CDM,172,RC,,,,,facility,both,,,,3553,2664.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
SCOPOLAMINE 1 MG/3DAYS PT72,172090,CDM,250,RC,50742050510,NDC,,,facility,both,1,UN,,43.15,32.36,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE 1 MG/3DAYS PT72,172090,CDM,250,RC,10019055304,NDC,,,facility,both,1,UN,,43.1,32.32,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,172226,CDM,250,RC,MHS1ML,HCPCS,409729501,NDC,facility,both,1,ML,,8.1,6.07,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,172226,CDM,250,RC,MHS1ML,HCPCS,65219005429,NDC,facility,both,1,ML,,10.01,7.51,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 1000 MG/10ML SOLN,172233,CDM,636,RC,J2800,HCPCS,70069010125,NDC,facility,both,10,ML,,65.1,48.82,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 1000 MG/10ML SOLN,172233,CDM,636,RC,J2800,HCPCS,70069010105,NDC,facility,both,10,ML,,71.45,53.59,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 1000 MG/10ML SOLN,172233,CDM,636,RC,J2800,HCPCS,43598083911,NDC,facility,both,10,ML,,63.54,47.65,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 1000 MG/10ML SOLN 10 ML VIAL,172233,CDM,636,RC,J2800,HCPCS,70069010105,NDC,facility,both,10,ML,,71.45,53.59,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 1000 MG/10ML SOLN 10 ML VIAL,172233,CDM,636,RC,J2800,HCPCS,70069010125,NDC,facility,both,10,ML,,65.1,48.82,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 1000 MG/10ML SOLN 10 ML VIAL,172233,CDM,636,RC,J2800,HCPCS,43598083911,NDC,facility,both,10,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
RHO D IMMUNE GLOBULIN 1500 UNITS IM SOSY,172235,CDM,562780501,NDC,,,,,facility,both,300,EA,,252,189,,,,,,,,,,Gross Charge Type: Pharmacy
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,172236,CDM,44206030090,NDC,,,,,facility,both,100,ML,,20.75,15.56,,,,,,,,,,Gross Charge Type: Pharmacy
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,172236,CDM,44206030001,NDC,,,,,facility,both,100,ML,,17.59,13.19,,,,,,,,,,Gross Charge Type: Pharmacy
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML SOSY,172236,CDM,636,RC,J2791,HCPCS,44206030001,NDC,facility,both,100,UN,,13.74,10.31,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL-PETROLATUM EMOLLIENT OINT,1724,CDM,250,RC,MHS1GM,HCPCS,72140063377,NDC,facility,both,1,GM,,22.7,17.02,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL-PETROLATUM EMOLLIENT OINT,1724,CDM,250,RC,MHS1GM,HCPCS,11940152006,NDC,facility,both,1,GM,,20.65,15.49,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL-PETROLATUM EMOLLIENT OINT 396 G JAR,1724,CDM,250,RC,MHS1GM,HCPCS,72140003147,NDC,facility,both,1,GM,,0.14,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL-PETROLATUM EMOLLIENT OINT 50 G TUBE,1724,CDM,250,RC,MHS1GM,HCPCS,72140045231,NDC,facility,both,1,GM,,0.87,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN,172418,CDM,250,RC,72572048101,NDC,,,facility,both,16,ML,,97.8,73.35,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN,172418,CDM,250,RC,72572048101,NDC,,,facility,both,8,ML,,108.5,81.38,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN,172418,CDM,250,RC,67457085204,NDC,,,facility,both,4,ML,,68.75,51.56,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN,172418,CDM,250,RC,67457085204,NDC,,,facility,both,8,ML,,43.78,32.83,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN,172418,CDM,250,RC,72572048101,NDC,,,facility,both,4,ML,,133.4,100.05,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL,172418,CDM,250,RC,67457085204,NDC,,,facility,both,4,ML,,38.84,29.13,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL,172418,CDM,250,RC,70121157607,NDC,,,facility,both,8,ML,,48.25,36.19,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL,172418,CDM,250,RC,67457085204,NDC,,,facility,both,16,ML,,31.29,23.47,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL,172418,CDM,250,RC,67457085204,NDC,,,facility,both,8,ML,,43.78,32.83,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL,172418,CDM,250,RC,72572048101,NDC,,,facility,both,4,ML,,133.4,100.05,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL,172418,CDM,250,RC,72572048101,NDC,,,facility,both,8,ML,,108.5,81.38,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL,172418,CDM,250,RC,72572048101,NDC,,,facility,both,16,ML,,97.8,73.35,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL,172418,CDM,250,RC,70121157607,NDC,,,facility,both,4,ML,,48.32,36.24,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G SOLR 1 EACH VIAL,172604,CDM,636,RC,J0714,HCPCS,456270010,NDC,facility,both,0.625,GM,,376.4,282.3,,,,,,,,,,Gross Charge Type: Pharmacy
ISAVUCONAZONIUM SULFATE 186 MG CAPS,172607,CDM,250,RC,469052002,NDC,,,facility,both,2,UN,,160.02,120.02,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE SUCCINATE ER 25 MG TB24,172685,CDM,250,RC,51991000633,NDC,,,facility,both,1,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE SUCCINATE ER 25 MG TB24,172685,CDM,250,RC,54060313,NDC,,,facility,both,2,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE SUCCINATE ER 25 MG TB24,172685,CDM,250,RC,51991000633,NDC,,,facility,both,2,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 5 MG TABS,172791,CDM,250,RC,55513080060,NDC,,,facility,both,0.5,UN,,16.05,12.04,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 5 MG TABS,172791,CDM,250,RC,55513080060,NDC,,,facility,both,1.5,UN,,15.15,11.36,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 5 MG TABS,172791,CDM,250,RC,55513080060,NDC,,,facility,both,1,UN,,23.73,17.8,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 5 MG TABS,172791,CDM,250,RC,55513080060,NDC,,,facility,both,2,UN,,18.82,14.12,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Newborn Level 3,1730000001,CDM,173,RC,,,,,facility,both,,,,4895,3671.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
GLUCAGON 1 MG SOLR,173197,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,both,1,ME,,341.64,256.23,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG SOLR 1 EACH VIAL,173197,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,both,1,ME,,261.28,195.96,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM 99 MG TABS,17357,CDM,250,RC,30768000405,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM 99 MG TABS,17357,CDM,250,RC,30768000405,NDC,,,facility,both,2,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM ACETATE 2 MEQ/ML SOLN 20 ML VIAL,17358,CDM,250,RC,MHS1ML,HCPCS,51754200104,NDC,facility,both,1,ML,,5.18,3.89,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM ACETATE 2 MEQ/ML SOLN 20 ML VIAL,17358,CDM,250,RC,MHS1ML,HCPCS,409818301,NDC,facility,both,1,ML,,5.23,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM ACETATE 2 MEQ/ML SOLN 50 ML VIAL,17358,CDM,250,RC,MHS1ML,HCPCS,409329451,NDC,facility,both,1,ML,,1.42,1.06,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARBONATE-POTASSIUM CITRATE 25 MEQ TBEF,17362,CDM,250,RC,245532630,NDC,,,facility,both,2,UN,,5.52,4.14,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARBONATE-POTASSIUM CITRATE 25 MEQ TBEF,17362,CDM,250,RC,51801000530,NDC,,,facility,both,1,UN,,8.05,6.04,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARBONATE-POTASSIUM CITRATE 25 MEQ TBEF,17362,CDM,250,RC,245532630,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR TETRASODIUM 50 MG SOLR 1 EACH VIAL,173664,CDM,636,RC,C9460,HCPCS,10122062010,NDC,facility,both,1,ME,,41.04,30.78,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.75 % SPINAL IN 8.25% D5W 7.5 MG/ML SOLN,17369,CDM,636,RC,J0665,HCPCS,409361301,NDC,facility,both,0.5,ME,,1.34,1,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN,17371,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,both,20,ML,,2.5,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN,17371,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,both,40,ML,,1.32,0.99,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096510,NDC,facility,both,2.5,ML,,15.93,11.95,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096510,NDC,facility,both,7.5,ML,,6.11,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409665106,NDC,facility,both,5,ML,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096510,NDC,facility,both,15,ML,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409665106,NDC,facility,both,10,ML,,5.34,4,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096510,NDC,facility,both,10,ML,,4.74,3.55,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096510,NDC,facility,both,20,ML,,2.56,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096510,NDC,facility,both,5,ML,,7.77,5.83,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096510,NDC,facility,both,50,ML,,1.14,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096510,NDC,facility,both,27.5,ML,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409665106,NDC,facility,both,20,ML,,2.96,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096510,NDC,facility,both,30,ML,,1.77,1.33,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,both,40,ML,,1.32,0.99,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,both,60,ML,,0.92,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409665305,NDC,facility,both,40,ML,,1.65,1.24,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,both,20,ML,,2.5,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409665305,NDC,facility,both,10,ML,,5.22,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,both,10,ML,,4.87,3.65,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409665305,NDC,facility,both,20,ML,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,both,17.5,ML,,2.76,2.07,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409665305,NDC,facility,both,15,ML,,3.64,2.73,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,both,30,ML,,1.71,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,both,15,ML,,3.29,2.47,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.515,ML,,24.88,18.66,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.425,ML,,24.8,18.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.34,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.58,ML,,24.92,18.69,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.97,ML,,48.9,36.68,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.83,ML,,48.65,36.49,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,12.5,ML,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.095,ML,,49.1,36.82,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.29,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.015,ML,,48.95,36.71,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.895,ML,,48.75,36.56,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.115,ML,,24.55,18.41,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.525,ML,,17.1,12.82,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.16,ML,,16.92,12.69,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,22.5,ML,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.8,ML,,48.6,36.45,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.355,ML,,47.85,35.89,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.135,ML,,16.9,12.68,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.81,ML,,25.1,18.82,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.78,ML,,48.55,36.41,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.27,ML,,24.68,18.51,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.03,ML,,25.28,18.96,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.095,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.4,ML,,24.78,18.58,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.9,ML,,48.75,36.56,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.275,ML,,16.97,12.72,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.56,ML,,48.2,36.15,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.295,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,15,ML,,4.66,3.5,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.955,ML,,48.85,36.64,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.385,ML,,24.78,18.58,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.59,ML,,48.25,36.19,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.99,ML,,48.9,36.68,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.51,ML,,24.88,18.66,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.02,ML,,25.28,18.96,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.065,ML,,25.3,18.98,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.1,ML,,16.88,12.66,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.57,ML,,48.25,36.19,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.665,ML,,48.4,36.3,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.275,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.465,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.525,ML,,48.15,36.11,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.42,ML,,47.95,35.96,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.6,ML,,24.95,18.71,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.115,ML,,16.88,12.66,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.81,ML,,48.6,36.45,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.85,ML,,48.7,36.52,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.575,ML,,24.92,18.69,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.325,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.41,ML,,24.8,18.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.935,ML,,48.8,36.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.125,ML,,24.58,18.43,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.08,ML,,49.05,36.79,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.4,ML,,47.95,35.96,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.285,ML,,16.98,12.74,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.88,ML,,48.75,36.56,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.065,ML,,49.05,36.79,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.805,ML,,25.1,18.82,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.17,ML,,16.92,12.69,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.01,ML,,48.95,36.71,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.71,ML,,25.02,18.77,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.845,ML,,48.7,36.52,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,32.5,ML,,2.9,2.17,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.46,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.355,ML,,17.02,12.76,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.39,ML,,24.78,18.58,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.73,ML,,25.05,18.79,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.45,ML,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,45,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.2,ML,,24.62,18.47,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.685,ML,,25,18.75,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.945,ML,,48.85,36.64,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.975,ML,,48.9,36.68,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.09,ML,,49.05,36.79,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.33,ML,,24.72,18.54,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.655,ML,,24.98,18.73,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.035,ML,,25.28,18.96,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.82,ML,,25.1,18.82,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.73,ML,,48.5,36.38,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.615,ML,,24.95,18.71,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.44,ML,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.84,ML,,48.65,36.49,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.1,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,10,ML,,6.26,4.7,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.44,ML,,17.07,12.8,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.2,ML,,16.93,12.7,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.985,ML,,25.22,18.92,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.245,ML,,24.65,18.49,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.06,ML,,49.05,36.79,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.925,ML,,25.2,18.9,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.045,ML,,25.28,18.96,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.82,ML,,17.25,12.94,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.5,ML,,17.08,12.81,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,25,ML,,3.39,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,3.12,ML,,13.05,9.79,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,3.365,ML,,13.15,9.86,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.425,ML,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,42.5,ML,,2.55,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.65,ML,,24.98,18.73,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.765,ML,,48.55,36.41,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.9,ML,,25.18,18.88,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.75,ML,,48.55,36.41,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.03,ML,,49,36.75,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.495,ML,,24.85,18.64,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.23,ML,,16.95,12.71,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.175,ML,,24.6,18.45,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096505,NDC,facility,both,5,ML,,10.45,7.84,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.24,ML,,24.65,18.49,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,35,ML,,2.84,2.13,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.315,ML,,24.72,18.54,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.925,ML,,48.8,36.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.71,ML,,48.45,36.34,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,5,ML,,11.02,8.26,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.5,ML,,48.1,36.08,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.465,ML,,24.82,18.62,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.99,ML,,25.25,18.94,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.53,ML,,24.88,18.66,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.65,ML,,48.35,36.26,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096505,NDC,facility,both,10,ML,,5.71,4.28,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.525,ML,,24.88,18.66,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.585,ML,,48.25,36.19,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.575,ML,,48.25,36.19,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.885,ML,,48.75,36.56,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.96,ML,,48.85,36.64,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.205,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.47,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.585,ML,,24.92,18.69,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.32,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.045,ML,,49,36.75,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.45,ML,,24.82,18.62,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.725,ML,,25.02,18.77,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.93,ML,,48.8,36.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.47,ML,,24.85,18.64,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.41,ML,,47.95,35.96,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.055,ML,,25.3,18.98,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.64,ML,,24.98,18.73,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.455,ML,,24.82,18.62,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,3.15,ML,,13.06,9.8,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.965,ML,,25.22,18.92,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.11,ML,,24.55,18.41,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.985,ML,,48.9,36.68,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.28,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.48,ML,,24.85,18.64,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.085,ML,,49.05,36.79,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.21,ML,,24.62,18.47,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.69,ML,,25,18.75,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.405,ML,,24.8,18.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.14,ML,,24.58,18.43,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.725,ML,,48.5,36.38,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.39,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.365,ML,,24.75,18.56,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.075,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.705,ML,,25.02,18.77,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.905,ML,,48.8,36.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.82,ML,,48.65,36.49,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,3.875,ML,,13.35,10.01,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.505,ML,,24.88,18.66,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.365,ML,,17.02,12.76,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.095,ML,,25.32,18.99,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.135,ML,,24.58,18.43,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.08,ML,,25.3,18.98,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.57,ML,,24.92,18.69,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.165,ML,,24.6,18.45,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.285,ML,,24.7,18.52,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,4,ML,,13.4,10.05,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.55,ML,,24.9,18.68,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.92,ML,,48.8,36.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.445,ML,,24.82,18.62,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,63323096505,NDC,facility,both,20,ML,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.68,ML,,25,18.75,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,2.85,ML,,17.27,12.95,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.695,ML,,25.02,18.77,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,1.7,ML,,25.02,18.77,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL,17371,CDM,636,RC,J3480,HCPCS,409663501,NDC,facility,both,0.365,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG TABS,173715,CDM,250,RC,78065920,NDC,,,facility,both,1,UN,,26.55,19.91,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG TABS,173715,CDM,250,RC,78065920,NDC,,,facility,both,0.5,UN,,17.85,13.39,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG TABS,173716,CDM,250,RC,78077720,NDC,,,facility,both,1,UN,,26.55,19.91,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG TABS,173716,CDM,250,RC,78077767,NDC,,,facility,both,1,UN,,26.55,19.91,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG TABS,173716,CDM,250,RC,78077720,NDC,,,facility,both,0.5,UN,,17.85,13.39,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 97-103 MG TABS,173717,CDM,250,RC,78069620,NDC,,,facility,both,1,UN,,26.53,19.89,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 97-103 MG TABS,173717,CDM,250,RC,78069620,NDC,,,facility,both,0.5,UN,,17.76,13.32,,,,,,,,,,Gross Charge Type: Pharmacy
BREXPIPRAZOLE 1 MG TABS,173751,CDM,250,RC,59148003713,NDC,,,facility,both,3,UN,,72.08,54.06,,,,,,,,,,Gross Charge Type: Pharmacy
BREXPIPRAZOLE 1 MG TABS,173751,CDM,250,RC,59148003713,NDC,,,facility,both,1.5,UN,,59.78,44.83,,,,,,,,,,Gross Charge Type: Pharmacy
BREXPIPRAZOLE 1 MG TABS,173751,CDM,250,RC,59148003713,NDC,,,facility,both,2,UN,,76.19,57.14,,,,,,,,,,Gross Charge Type: Pharmacy
BREXPIPRAZOLE 1 MG TABS,173751,CDM,250,RC,59148003713,NDC,,,facility,both,1,UN,,83.97,62.97,,,,,,,,,,Gross Charge Type: Pharmacy
BREXPIPRAZOLE 1 MG TABS,173751,CDM,250,RC,59148003713,NDC,,,facility,both,0.5,UN,,45.81,34.36,,,,,,,,,,Gross Charge Type: Pharmacy
BREXPIPRAZOLE 4 MG TABS,173754,CDM,250,RC,59148004013,NDC,,,facility,both,1,UN,,84.14,63.1,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ PACK,17383,CDM,250,RC,245036089,NDC,,,facility,both,2,UN,,10.88,8.16,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ PACK,17383,CDM,250,RC,245036089,NDC,,,facility,both,1,UN,,15.3,11.48,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ PACK,17383,CDM,250,RC,603155404,NDC,,,facility,both,1,UN,,16.2,12.15,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ PACK,17383,CDM,250,RC,603155404,NDC,,,facility,both,2,UN,,11.75,8.81,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ PACK,17383,CDM,250,RC,245036030,NDC,,,facility,both,1,UN,,16.25,12.19,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ PACK,17383,CDM,250,RC,245036030,NDC,,,facility,both,3,UN,,10.22,7.66,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ PACK,17383,CDM,250,RC,245036030,NDC,,,facility,both,2,UN,,11.8,8.85,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN HCL 400 MG/250ML SOLN,173853,CDM,636,RC,J2280,HCPCS,67457032325,NDC,facility,both,100,ME,,40.6,30.45,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN HCL 400 MG/250ML SOLN,173853,CDM,636,RC,J2280,HCPCS,63323085074,NDC,facility,both,100,ME,,33.72,25.29,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174254,CDM,636,RC,J3475,HCPCS,47335099201,NDC,facility,both,500,ME,,14.4,10.8,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174254,CDM,636,RC,J3475,HCPCS,67457055300,NDC,facility,both,500,ME,,15.39,11.54,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174254,CDM,636,RC,J3475,HCPCS,44567042024,NDC,facility,both,500,ME,,13.79,10.34,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174254,CDM,636,RC,J3475,HCPCS,409672911,NDC,facility,both,500,ME,,19.42,14.57,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174254,CDM,636,RC,J3475,HCPCS,63323010601,NDC,facility,both,500,ME,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174254,CDM,636,RC,J3475,HCPCS,409672924,NDC,facility,both,500,ME,,18.96,14.22,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174254,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,both,500,ME,,13.38,10.03,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN 50 ML FLEX CONT,174254,CDM,636,RC,J3475,HCPCS,409672924,NDC,facility,both,500,ME,,18.92,14.19,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174255,CDM,636,RC,J3475,HCPCS,409412101,NDC,facility,both,500,ME,,22.21,16.65,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174255,CDM,636,RC,J3475,HCPCS,409672923,NDC,facility,both,500,ME,,7.68,5.76,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174255,CDM,636,RC,J3475,HCPCS,47335099201,NDC,facility,both,500,ME,,8.78,6.59,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174255,CDM,636,RC,J3475,HCPCS,67457055300,NDC,facility,both,500,ME,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174255,CDM,636,RC,J3475,HCPCS,63323010601,NDC,facility,both,500,ME,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174255,CDM,636,RC,J3475,HCPCS,67457055400,NDC,facility,both,500,ME,,6.82,5.11,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174255,CDM,636,RC,J3475,HCPCS,70121172009,NDC,facility,both,500,ME,,7.43,5.57,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174255,CDM,636,RC,J3475,HCPCS,63323010615,NDC,facility,both,500,ME,,6.13,4.6,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN,174255,CDM,636,RC,J3475,HCPCS,338171540,NDC,facility,both,500,ME,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML SOLN 100 ML FLEX CONT,174255,CDM,636,RC,J3475,HCPCS,63323010601,NDC,facility,both,500,ME,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAMS IN 500 ML 40 MG/ML SOLN,174256,CDM,636,RC,J3475,HCPCS,63323010601,NDC,facility,both,500,ME,,0.58,0.44,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAMS IN 500 ML 40 MG/ML SOLN,174256,CDM,636,RC,J3475,HCPCS,409672923,NDC,facility,both,500,ME,,4.53,3.4,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAMS IN 500 ML 40 MG/ML SOLN,174256,CDM,636,RC,J3475,HCPCS,63323010615,NDC,facility,both,500,ME,,1.38,1.03,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAMS IN 500 ML 40 MG/ML SOLN,174256,CDM,636,RC,J3475,HCPCS,70121172009,NDC,facility,both,500,ME,,7.43,5.57,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAMS IN 500 ML 40 MG/ML SOLN,174256,CDM,636,RC,J3475,HCPCS,67457055400,NDC,facility,both,500,ME,,0.89,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML SOSY,174259,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,both,0.5,ML,,0.89,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML SOSY,174259,CDM,636,RC,Q5101,HCPCS,61314031810,NDC,facility,both,0.5,ML,,0.89,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML SOSY,174259,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,both,0.2,ML,,1.14,0.85,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML SOSY,174259,CDM,636,RC,Q5101,HCPCS,61314031801,NDC,facility,both,0.3,ML,,1,0.75,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 480 MCG/0.8 ML SOSY,174260,CDM,636,RC,Q5101,HCPCS,61314032610,NDC,facility,both,0.8,ML,,0.84,0.63,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 480 MCG/0.8 ML SOSY,174260,CDM,636,RC,Q5101,HCPCS,61314032601,NDC,facility,both,0.8,ML,,0.84,0.63,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML SOLN 10 ML VIAL,174261,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,both,10,ME,,258.42,193.82,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML SOLN 50 ML VIAL,174262,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,both,10,ME,,264.31,198.23,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM 6 MG/0.6ML SOSY,174264,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,both,0.5,ME,,838.16,628.62,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM 6 MG/0.6ML PSKT,174265,CDM,636,RC,J2506,HCPCS,55513019201,NDC,facility,both,0.5,ME,,850.34,637.76,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML SOLN,174274,CDM,636,RC,J3230,HCPCS,641139835,NDC,facility,both,50,ME,,117.9,88.42,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML SOLN 2 ML AMPULE,174274,CDM,636,RC,J3230,HCPCS,641139835,NDC,facility,both,50,ME,,117.9,88.42,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG TB24,174275,CDM,250,RC,62175031037,NDC,,,facility,both,1,UN,,13.2,9.9,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG TB24,174275,CDM,250,RC,62175031037,NDC,,,facility,both,3,UN,,9.7,7.28,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG TB24,174275,CDM,250,RC,62037072501,NDC,,,facility,both,1,UN,,12.95,9.71,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG TB24,174275,CDM,250,RC,62175031037,NDC,,,facility,both,2,UN,,10.6,7.95,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA 100 MCG/ML SOLN,174282,CDM,636,RC,J0882,HCPCS,55513000504,NDC,facility,both,1.5,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA 100 MCG/ML SOLN,174282,CDM,636,RC,J0882,HCPCS,55513000504,NDC,facility,both,0.5,ML,,21.25,15.94,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA 60 MCG/ML SOLN,174284,CDM,636,RC,J0882,HCPCS,55513000404,NDC,facility,both,0.666666667,ML,,24.37,18.27,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA 60 MCG/ML SOLN,174284,CDM,636,RC,J0882,HCPCS,55513000401,NDC,facility,both,0.3333,ML,,23.67,17.75,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA 60 MCG/ML SOLN,174284,CDM,636,RC,J0882,HCPCS,55513000401,NDC,facility,both,0.666666667,ML,,24.37,18.28,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 60 MG TABS,174339,CDM,250,RC,186077660,NDC,,,facility,both,1,UN,,21.2,15.9,,,,,,,,,,Gross Charge Type: Pharmacy
POVIDONE-IODINE 10 % OINT,17437,CDM,250,RC,536127180,NDC,,,facility,both,1,GR,,38.75,29.06,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOSY,174387,CDM,250,RC,70092111944,NDC,,,facility,both,4.5,ML,,43.35,32.51,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOSY,174387,CDM,250,RC,70092111944,NDC,,,facility,both,2,ML,,37.4,28.05,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOSY,174387,CDM,250,RC,70092111944,NDC,,,facility,both,7.5,ML,,25.25,18.94,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOSY,174387,CDM,250,RC,70092111944,NDC,,,facility,both,4,ML,,42.2,31.65,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOSY,174387,CDM,250,RC,70092111944,NDC,,,facility,both,5,ML,,44.55,33.41,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOSY,174387,CDM,250,RC,70092111944,NDC,,,facility,both,10,ML,,28.18,21.13,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOSY 5 ML SYRINGE,174387,CDM,250,RC,70092111944,NDC,,,facility,both,5.5,ML,,22.88,17.16,,,,,,,,,,Gross Charge Type: Pharmacy
POVIDONE-IODINE 10 % SOLN,17440,CDM,250,RC,904110309,NDC,,,facility,both,1,ML,,20.35,15.26,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG CAPS,17469,CDM,250,RC,51079063120,NDC,,,facility,both,2,UN,,7.88,5.91,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG CAPS,17469,CDM,250,RC,51079063120,NDC,,,facility,both,1.5,UN,,6.92,5.19,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG CAPS,17469,CDM,250,RC,51079063120,NDC,,,facility,both,1,UN,,11.41,8.56,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG CAPS,17469,CDM,250,RC,51079063120,NDC,,,facility,both,5,UN,,5.17,3.88,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG CAPS,17469,CDM,250,RC,51079063120,NDC,,,facility,both,0.5,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG SOLR 1 EACH VIAL,174691,CDM,636,RC,J9352,HCPCS,59676061001,NDC,facility,both,0.1,ME,,938.8,704.1,,,,,,,,,,Gross Charge Type: Pharmacy
IDARUCIZUMAB 2.5 GM/50ML SOLN,174783,CDM,636,RC,C9399,HCPCS,597019705,NDC,facility,both,1,EA,,5459.68,4094.76,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE (PHOS BINDER) 667 MG CAPS,174796,CDM,250,RC,29033002602,NDC,,,facility,both,1,UN,,9.2,6.9,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE (PHOS BINDER) 667 MG CAPS,174796,CDM,250,RC,68084047901,NDC,,,facility,both,3,UN,,5.33,4,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE (PHOS BINDER) 667 MG CAPS,174796,CDM,250,RC,781208102,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE (PHOS BINDER) 667 MG CAPS,174796,CDM,250,RC,68084047901,NDC,,,facility,both,1,UN,,10.65,7.99,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE (PHOS BINDER) 667 MG CAPS,174796,CDM,250,RC,68084047901,NDC,,,facility,both,2,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOME 4.3 MG/ML INJ 10 ML VIAL,174801,CDM,636,RC,J9205,HCPCS,15054004301,NDC,facility,both,1,ME,,182.31,136.73,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,180,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,145,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,140,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,18.6,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,186,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,93,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,70,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,8,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,80,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,65,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,215,ML,,44.85,33.64,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,139.5,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,5,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,50,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,35,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,120,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,58,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,167,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,55.8,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,558,ML,,42.78,32.09,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,36,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,29.5,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,100,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,115,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,2,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,20,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,200,ML,,44.85,33.64,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,176,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,95,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,86,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,111,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,25,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,1053,ML,,39.57,29.67,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,31,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,132,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,85,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,160,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,187,ML,,44.85,33.64,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,175,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,96,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,426,ML,,42.78,32.09,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,167.4,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,45,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,372,ML,,44.85,33.64,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,55,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,10,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,38,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,46,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,130,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,110,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,105,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,68,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,75,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,170,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,148.8,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,60,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,6,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,148,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,28,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,900,ML,,40.23,30.17,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,90,ML,,46.54,34.91,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,3,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,300,ML,,44.85,33.64,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,30,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,4,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,1500,ML,,38.47,28.85,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,15,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,150,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,97,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,400,ML,,42.78,32.09,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,40,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 96 % SUSR,17495,CDM,250,RC,32909075003,NDC,,,facility,both,230,ML,,44.85,33.64,,,,,,,,,,Gross Charge Type: Pharmacy
MEPOLIZUMAB 100 MG SOLR,174968,CDM,636,RC,J2182,HCPCS,173088101,NDC,facility,both,1,ME,,73.09,54.81,,,,,,,,,,Gross Charge Type: Pharmacy
PEDIATRIC DEKAS PLUS VITAMIN LIQD,175019,CDM,250,RC,MHS1mL,HCPCS,55520000163,NDC,facility,both,1,ML,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
DABIGATRAN 110 MG CAPS,175198,CDM,250,RC,597010860,NDC,,,facility,both,1,UN,,20.15,15.11,,,,,,,,,,Gross Charge Type: Pharmacy
PATIROMER SORBITEX CALCIUM 8.4 G PACK,175221,CDM,250,RC,53436008430,NDC,,,facility,both,2,UN,,52.6,39.45,,,,,,,,,,Gross Charge Type: Pharmacy
PATIROMER SORBITEX CALCIUM 8.4 G PACK,175221,CDM,250,RC,53436008430,NDC,,,facility,both,1,UN,,58.6,43.95,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/0.1ML LIQD,175240,CDM,250,RC,45802081100,NDC,,,facility,both,1,UN,,87.1,65.32,,,,,,,,,,Gross Charge Type: Pharmacy
ELOTUZUMAB 25 MG/ML SOLR 1 EACH VIAL,175284,CDM,636,RC,J9176,HCPCS,3229111,NDC,facility,both,1,ME,,17.8,13.35,,,,,,,,,,Gross Charge Type: Pharmacy
ELOTUZUMAB 25 MG/ML SOLR 1 EACH VIAL,175285,CDM,636,RC,J9176,HCPCS,3452211,NDC,facility,both,1,ME,,20.76,15.57,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 1 % SUSP,17531,CDM,250,RC,MHS1ML,HCPCS,60758011905,NDC,facility,both,1,ML,,16.9,12.68,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 1 % SUSP 5 ML BOTTLE,17531,CDM,250,RC,MHS1ML,HCPCS,60758011905,NDC,facility,both,1,ML,,16.9,12.68,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 100 MG/4ML SOLN 4 ML VIAL,175346,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,both,1,ME,,48.81,36.61,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 5 MG/5ML SOLN,17546,CDM,636,RC,J7512,HCPCS,54372263,NDC,facility,both,1,ME,,1.26,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 1 MG TABS,17547,CDM,636,RC,J7512,HCPCS,54873925,NDC,facility,both,1,ME,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 1 MG TABS,17547,CDM,636,RC,J7512,HCPCS,54474125,NDC,facility,both,1,ME,,1.48,1.11,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 1 MG TABS,17547,CDM,636,RC,J7512,HCPCS,59651048401,NDC,facility,both,1,ME,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 1 MG TABS 100 EACH BOX,17547,CDM,636,RC,J7512,HCPCS,54873925,NDC,facility,both,1,ME,,2.26,1.7,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG OR TABS,17548,CDM,54001720,NDC,,,,,facility,both,1,EA,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG TABS,17548,CDM,636,RC,J7512,HCPCS,904692361,NDC,facility,both,1,ME,,0.66,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG TABS,17548,CDM,636,RC,J7512,HCPCS,54001720,NDC,facility,both,1,ME,,0.71,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG TABS,17548,CDM,636,RC,J7512,HCPCS,60687013401,NDC,facility,both,1,ME,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG TABS,17548,CDM,636,RC,J7512,HCPCS,54001725,NDC,facility,both,1,ME,,0.78,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 2.5 MG TABS,17549,CDM,636,RC,J7512,HCPCS,54874025,NDC,facility,both,1,ME,,1.77,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 2.5 MG TABS,17549,CDM,636,RC,J7512,HCPCS,54474225,NDC,facility,both,1,ME,,1.71,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG OR TABS,17550,CDM,487020101,NDC,,,,,facility,both,1,ML,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG OR TABS,17550,CDM,904712761,NDC,,,,,facility,both,1,EA,,0.22,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG OR TABS,17550,CDM,60687014501,NDC,,,,,facility,both,1,EA,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG OR TABS,17550,CDM,54001820,NDC,,,,,facility,both,1,EA,,0.18,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG TABS,17550,CDM,636,RC,J7512,HCPCS,59746017509,NDC,facility,both,1,ME,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG TABS,17550,CDM,636,RC,J7512,HCPCS,54001820,NDC,facility,both,1,ME,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG TABS,17550,CDM,636,RC,J7512,HCPCS,60687014501,NDC,facility,both,1,ME,,0.22,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG TABS,17550,CDM,636,RC,J7512,HCPCS,59746017506,NDC,facility,both,1,ME,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG TABS,17550,CDM,636,RC,J7512,HCPCS,904712761,NDC,facility,both,1,ME,,0.21,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 5 MG TABS,17552,CDM,636,RC,J7512,HCPCS,60687012201,NDC,facility,both,1,ME,,1.06,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 5 MG TABS,17552,CDM,636,RC,J7512,HCPCS,54872425,NDC,facility,both,1,ME,,1.06,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 5 MG TABS,17552,CDM,636,RC,J7512,HCPCS,603533732,NDC,facility,both,1,ME,,1.39,1.04,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 5 MG TABS 100 EACH BOX,17552,CDM,636,RC,J7512,HCPCS,54872425,NDC,facility,both,1,ME,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG TABS,17553,CDM,636,RC,J7512,HCPCS,59651048901,NDC,facility,both,1,ME,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG TABS,17553,CDM,636,RC,J7512,HCPCS,54001920,NDC,facility,both,1,ME,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.75,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.5,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,2.426,ML,,358.68,269.01,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,2.5,ML,,358.68,269.01,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,1.3,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,3,ML,,357.98,268.48,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.8,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,6,ML,,353.53,265.15,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.6,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.2,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,20,ML,,282.57,211.93,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,2,ML,,369.52,277.14,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,1.25,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.722,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,1.8,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.1,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,1,ML,,370.04,277.53,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,1.6,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,4,ML,,358.5,268.87,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.4,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,12,ML,,282.58,211.93,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,1.2,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,1.896,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.04,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.35,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.9,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,1.5,ML,,369.96,277.47,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.02,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 200 MG/2ML SOLN,175598,CDM,250,RC,6542312,NDC,,,facility,both,0.7,ML,,370.2,277.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML SOLN,175600,CDM,250,RC,6542515,NDC,,,facility,both,2,ML,,287.79,215.84,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML SOLN,175600,CDM,250,RC,6542515,NDC,,,facility,both,1,ML,,167.4,125.55,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 1.5 MG CAPS,175867,CDM,250,RC,61874011530,NDC,,,facility,both,4,UN,,66.39,49.79,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 1.5 MG CAPS,175867,CDM,250,RC,61874011520,NDC,,,facility,both,2,UN,,71.4,53.55,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 1.5 MG CAPS,175867,CDM,250,RC,61874011530,NDC,,,facility,both,1,UN,,79.45,59.59,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 1.5 MG CAPS,175867,CDM,250,RC,61874011530,NDC,,,facility,both,3,UN,,68.25,51.19,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 1.5 MG CAPS,175867,CDM,250,RC,61874011520,NDC,,,facility,both,1,UN,,79.45,59.59,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 1.5 MG CAPS,175867,CDM,250,RC,61874011520,NDC,,,facility,both,3,UN,,68.25,51.19,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 1.5 MG CAPS,175867,CDM,250,RC,61874011520,NDC,,,facility,both,4,UN,,66.39,49.79,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 1.5 MG CAPS,175867,CDM,250,RC,61874011530,NDC,,,facility,both,2,UN,,71.95,53.96,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 3 MG CAPS,175868,CDM,250,RC,61874013020,NDC,,,facility,both,2,UN,,71.95,53.96,,,,,,,,,,Gross Charge Type: Pharmacy
CARIPRAZINE 3 MG CAPS,175868,CDM,250,RC,61874013020,NDC,,,facility,both,1,UN,,78,58.5,,,,,,,,,,Gross Charge Type: Pharmacy
INCOBOTULINUMTOXINA 200 UNITS IM SOLR,175874,CDM,259162001,NDC,,,,,facility,both,1,EA,,12.64,9.48,,,,,,,,,,Gross Charge Type: Pharmacy
INCOBOTULINUMTOXINA 200 UNITS SOLR,175874,CDM,636,RC,J0588,HCPCS,259162001,NDC,facility,both,1,UN,,9.64,7.23,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG CPEP,176162,CDM,250,RC,16714082901,NDC,,,facility,both,4,UN,,6.04,4.53,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG CPEP,176162,CDM,250,RC,16714082901,NDC,,,facility,both,2,UN,,8.28,6.21,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG CPEP,176162,CDM,250,RC,16714082901,NDC,,,facility,both,3,UN,,6.82,5.11,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG CPEP,176162,CDM,250,RC,16714082901,NDC,,,facility,both,1,UN,,12.35,9.26,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML SOLN,176164,CDM,636,RC,J2020,HCPCS,781343346,NDC,facility,both,200,ME,,53.13,39.85,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML SOLN,176164,CDM,636,RC,J2020,HCPCS,66794021943,NDC,facility,both,200,ME,,25.97,19.47,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML SOLN,176164,CDM,636,RC,J2020,HCPCS,57664068357,NDC,facility,both,200,ME,,34.73,26.05,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML SOLN,176164,CDM,636,RC,J2020,HCPCS,9514004,NDC,facility,both,200,ME,,57.45,43.09,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML SOLN,176164,CDM,636,RC,J2020,HCPCS,55150024251,NDC,facility,both,200,ME,,29.53,22.15,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML SOLN,176164,CDM,636,RC,J2020,HCPCS,143953410,NDC,facility,both,200,ME,,19.12,14.34,,,,,,,,,,Gross Charge Type: Pharmacy
CLADRIBINE 1 MG/ML SOLN 10 ML VIAL,176166,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,both,1,ME,,45.54,34.15,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 200 MG/20ML SOLN 20 ML VIAL,176168,CDM,250,RC,703204503,NDC,,,facility,both,20,ML,,170.3,127.72,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 200 MG/20ML SOLN 20 ML VIAL,176168,CDM,250,RC,63323041820,NDC,,,facility,both,20,ML,,164.15,123.11,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLISTIREX 30 MG/5ML SUER,176172,CDM,250,RC,MHS1ML,HCPCS,63824017563,NDC,facility,both,1,ML,,0.92,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLISTIREX 30 MG/5ML SUER,176172,CDM,250,RC,63824017563,NDC,,,facility,both,1,ML,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % SOLN,176186,CDM,250,RC,409428301,NDC,,,facility,both,1,ME,,33.05,24.79,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID 100 MG/ML SOLN,176187,CDM,250,RC,MHS1ML,HCPCS,43066000801,NDC,facility,both,1,ML,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID 100 MG/ML SOLN,176187,CDM,250,RC,MHS1ML,HCPCS,55150018810,NDC,facility,both,1,ML,,4.44,3.33,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID 100 MG/ML SOLN,176187,CDM,250,RC,MHS1ML,HCPCS,43066000810,NDC,facility,both,1,ML,,5.62,4.21,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID 100 MG/ML SOLN 10 ML VIAL,176187,CDM,250,RC,MHS1ML,HCPCS,55150018810,NDC,facility,both,1,ML,,4.44,3.33,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID 100 MG/ML SOLN 10 ML VIAL,176187,CDM,250,RC,MHS1ML,HCPCS,43066000801,NDC,facility,both,1,ML,,5.72,4.29,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID 100 MG/ML SOLN 10 ML VIAL,176187,CDM,250,RC,MHS1ML,HCPCS,43066000810,NDC,facility,both,1,ML,,4.89,3.67,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176193,CDM,636,RC,J2704,HCPCS,25021060820,NDC,facility,both,10,ME,,1.18,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176194,CDM,636,RC,J2704,HCPCS,69023420,NDC,facility,both,10,ME,,1.64,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176194,CDM,636,RC,J2704,HCPCS,409469933,NDC,facility,both,10,ME,,1.4,1.05,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176194,CDM,636,RC,J2704,HCPCS,25021060850,NDC,facility,both,10,ME,,1.47,1.1,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176195,CDM,636,RC,J2704,HCPCS,69024810,NDC,facility,both,10,ME,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176195,CDM,636,RC,J2704,HCPCS,25021060851,NDC,facility,both,10,ME,,0.87,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176195,CDM,636,RC,J2704,HCPCS,63323026978,NDC,facility,both,10,ME,,0.84,0.63,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176195,CDM,636,RC,J2704,HCPCS,63323026969,NDC,facility,both,10,ME,,0.83,0.63,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176195,CDM,636,RC,J2704,HCPCS,63323026965,NDC,facility,both,10,ME,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176195,CDM,636,RC,J2704,HCPCS,409469924,NDC,facility,both,10,ME,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176195,CDM,636,RC,J2704,HCPCS,16714069010,NDC,facility,both,10,ME,,0.78,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML EMUL,176195,CDM,636,RC,J2704,HCPCS,72572061201,NDC,facility,both,10,ME,,0.84,0.63,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/ML (2 ML) SOLN,176197,CDM,636,RC,J3010,HCPCS,63323080602,NDC,facility,both,0.1,ME,,36.08,27.06,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/ML (2 ML) SOLN,176197,CDM,636,RC,J3010,HCPCS,409909422,NDC,facility,both,0.1,ME,,30.47,22.85,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/ML (2 ML) SOLN,176197,CDM,636,RC,J3010,HCPCS,409909332,NDC,facility,both,0.1,ME,,32.94,24.7,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/ML (2 ML) SOLN,176197,CDM,636,RC,J3010,HCPCS,641602725,NDC,facility,both,0.1,ME,,36.45,27.34,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/ML (2 ML) SOLN 2 ML VIAL,176197,CDM,636,RC,J3010,HCPCS,409909422,NDC,facility,both,0.1,ME,,13.7,10.28,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/ML SOLN,176198,CDM,636,RC,J3010,HCPCS,409909425,NDC,facility,both,0.1,ME,,19.4,14.55,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/ML SOLN 5 ML VIAL,176198,CDM,636,RC,J3010,HCPCS,409909425,NDC,facility,both,0.1,ME,,14.96,11.22,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/ML SOLN,176199,CDM,636,RC,J3010,HCPCS,409909431,NDC,facility,both,0.1,ME,,5.8,4.35,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/ML SOLN 20 ML VIAL,176199,CDM,636,RC,J3010,HCPCS,409909431,NDC,facility,both,0.1,ME,,15.8,11.85,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68382010601,NDC,,,facility,both,1,UN,,8.46,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68382010601,NDC,,,facility,both,4,UN,,3.11,2.33,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68084031301,NDC,,,facility,both,1,UN,,9.18,6.88,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68084031301,NDC,,,facility,both,5,UN,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68084031301,NDC,,,facility,both,4,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68084031301,NDC,,,facility,both,3,UN,,4.07,3.05,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68382010601,NDC,,,facility,both,3,UN,,3.77,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68084031301,NDC,,,facility,both,2,UN,,5.38,4.03,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68084031301,NDC,,,facility,both,6,UN,,2.71,2.03,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SODIUM 125 MG CSDR,176201,CDM,250,RC,68084031301,NDC,,,facility,both,8,UN,,2.34,1.76,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,72888003501,NDC,,,facility,both,2,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,904630161,NDC,,,facility,both,2,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,51079093020,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,72888003501,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,51079093020,NDC,,,facility,both,4,UN,,2.14,1.6,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,904630161,NDC,,,facility,both,3,UN,,2.17,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,51079093020,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,904630161,NDC,,,facility,both,4,UN,,1.99,1.49,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,904630161,NDC,,,facility,both,1.5,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,904630161,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,904630161,NDC,,,facility,both,1,UN,,6.49,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,72888003501,NDC,,,facility,both,1,UN,,6.24,4.68,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 6.25 MG TABS,17632,CDM,250,RC,51079093020,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG TABS,17635,CDM,250,RC,904630361,NDC,,,facility,both,1.5,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG TABS,17635,CDM,250,RC,904630361,NDC,,,facility,both,0.75,UN,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG TABS,17635,CDM,250,RC,51079093220,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG TABS,17635,CDM,250,RC,51079093220,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG TABS,17635,CDM,250,RC,904630361,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG TABS,17635,CDM,250,RC,904630361,NDC,,,facility,both,1,UN,,6.5,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG TABS,17635,CDM,250,RC,904630361,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,904630261,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,93729501,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,51079093120,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,93729501,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,93729501,NDC,,,facility,both,4,UN,,1.89,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,904630261,NDC,,,facility,both,3,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,904630261,NDC,,,facility,both,1,UN,,6.27,4.7,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,51079093120,NDC,,,facility,both,2,UN,,3.62,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,93729501,NDC,,,facility,both,1,UN,,6.14,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG TABS,17636,CDM,250,RC,904630261,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE PRESERVATIVE FREE 3 % SOLN,176734,CDM,636,RC,J2401,HCPCS,143921010,NDC,facility,both,1,ME,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 2 MG/2ML SOSY,176748,CDM,636,RC,J2310,HCPCS,76329336901,NDC,facility,both,1,ME,,56.42,42.31,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 2 MG/2ML SOSY 2 ML SYRINGE,176748,CDM,636,RC,J2310,HCPCS,76329336901,NDC,facility,both,1,ME,,40.24,30.18,,,,,,,,,,Gross Charge Type: Pharmacy
FACTOR IX (RECOMBINANT) 1000 UNITS KIT,176754,CDM,636,RC,J7195,HCPCS,58394063503,NDC,facility,both,1,UN,,2.47,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
FACTOR IX (RECOMBINANT) 2000 UNITS KIT,176756,CDM,636,RC,J7195,HCPCS,58394063603,NDC,facility,both,1,UN,,2.44,1.83,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE-NACL 0.4-0.9 MG/10ML-% SOSY,176874,CDM,250,RC,70092148546,NDC,,,facility,both,2.5,ML,,34.15,25.61,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE-NACL 0.4-0.9 MG/10ML-% SOSY,176874,CDM,250,RC,70092148546,NDC,,,facility,both,3.75,ML,,38.7,29.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE-NACL 0.4-0.9 MG/10ML-% SOSY,176874,CDM,250,RC,70092148546,NDC,,,facility,both,2,ML,,32.3,24.22,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE-NACL 0.4-0.9 MG/10ML-% SOSY,176874,CDM,250,RC,70092148546,NDC,,,facility,both,1,ML,,28.65,21.49,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE-NACL 0.4-0.9 MG/10ML-% SOSY,176874,CDM,250,RC,70092148546,NDC,,,facility,both,10,ML,,61.5,46.12,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,11,ML,,70.2,52.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,13.75,ML,,70.2,52.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,70092108746,NDC,,,facility,both,4.5,ML,,84.35,63.26,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,3.5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,71449012615,NDC,,,facility,both,2.5,ML,,52.7,39.52,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,7,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,0.7,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,71449012615,NDC,,,facility,both,1,ML,,36.1,27.08,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,2,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,15,ML,,70.2,52.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,1.5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,71449012615,NDC,,,facility,both,4,ML,,65.7,49.28,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,12,ML,,70.2,52.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,5.5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,6.5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,9,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,6.25,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,4.5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,7.5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,3,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,71449012615,NDC,,,facility,both,1.5,ML,,41.6,31.2,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,6,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,70092108746,NDC,,,facility,both,7.5,ML,,107.25,80.44,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,1,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,10,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,8.5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,2.5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,70092108746,NDC,,,facility,both,5,ML,,88.15,66.11,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,70092108746,NDC,,,facility,both,2,ML,,65.2,48.9,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,70092108746,NDC,,,facility,both,6,ML,,95.75,71.81,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,70092108746,NDC,,,facility,both,10,ML,,126.35,94.76,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,0.5,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,70092108746,NDC,,,facility,both,2.5,ML,,69.05,51.79,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,8,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,4,ML,,95.15,71.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,70092108746,NDC,,,facility,both,3.5,ML,,76.7,57.52,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 200 MG/10ML SOSY,176879,CDM,250,RC,69374091910,NDC,,,facility,both,14,ML,,70.2,52.65,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200-25 MG TABS,176909,CDM,250,RC,61958200201,NDC,,,facility,both,1,UN,,115.65,86.74,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 125 MG/125 ML IN D5W 125-5 MG/125ML-% SOLN,176918,CDM,250,RC,70092157536,NDC,,,facility,both,15,ML,,91.7,68.78,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 125 MG/125 ML IN D5W 125-5 MG/125ML-% SOLN,176918,CDM,250,RC,70092157536,NDC,,,facility,both,125,ML,,96.96,72.72,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 10 MG TABS,176937,CDM,250,RC,74056114,NDC,,,facility,both,5,UN,,20.94,15.7,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 50 MG TABS,176938,CDM,250,RC,74056607,NDC,,,facility,both,1,UN,,524.85,393.64,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 100 MG TABS,176939,CDM,250,RC,74057630,NDC,,,facility,both,2,UN,,560.45,420.34,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 100 MG TABS,176939,CDM,250,RC,74057630,NDC,,,facility,both,1,UN,,805.8,604.35,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 100 MG TABS,176939,CDM,250,RC,74057630,NDC,,,facility,both,4,UN,,499.6,374.7,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG TABS,17697,CDM,250,RC,68084020301,NDC,,,facility,both,1.5,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG TABS,17697,CDM,250,RC,50268068715,NDC,,,facility,both,1,UN,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG TABS,17697,CDM,250,RC,50268068715,NDC,,,facility,both,0.8,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG TABS,17697,CDM,250,RC,50268068715,NDC,,,facility,both,2,UN,,5.22,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG TABS,17697,CDM,250,RC,50268068715,NDC,,,facility,both,1.5,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG TABS,17697,CDM,250,RC,50268068715,NDC,,,facility,both,0.5,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.4 G CAPS,176971,CDM,250,RC,37000040514,NDC,,,facility,both,6,UN,,1.53,1.15,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.4 G CAPS,176971,CDM,250,RC,37000040514,NDC,,,facility,both,6.5,UN,,1.33,1,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.4 G CAPS,176971,CDM,250,RC,37000040514,NDC,,,facility,both,1.3,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.2 MG/ML STANDARD PCA 0.2 MG/ML SOLN,176983,CDM,636,RC,70092111379,NDC,,,facility,both,0.1,ME,,105.05,78.79,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.2 MG/ML STANDARD PCA 0.2 MG/ML SOLN,176983,CDM,636,RC,J1170,HCPCS,70092111379,NDC,facility,both,0.1,ME,,52.52,39.39,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 3.125 MG TABS,17700,CDM,250,RC,904630061,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 3.125 MG TABS,17700,CDM,250,RC,904630061,NDC,,,facility,both,4,UN,,1.99,1.49,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 3.125 MG TABS,17700,CDM,250,RC,68382009201,NDC,,,facility,both,4,UN,,1.76,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 3.125 MG TABS,17700,CDM,250,RC,904630061,NDC,,,facility,both,2,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 3.125 MG TABS,17700,CDM,250,RC,68382009201,NDC,,,facility,both,2,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 3.125 MG TABS,17700,CDM,250,RC,904630061,NDC,,,facility,both,0.49984,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 3.125 MG TABS,17700,CDM,250,RC,904630061,NDC,,,facility,both,6,UN,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 3.125 MG TABS,17700,CDM,250,RC,904630061,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 3.125 MG TABS,17700,CDM,250,RC,68382009201,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
BRIVARACETAM 50 MG TABS,177123,CDM,250,RC,50474057066,NDC,,,facility,both,2,UN,,44.35,33.26,,,,,,,,,,Gross Charge Type: Pharmacy
BRIVARACETAM 50 MG TABS,177123,CDM,250,RC,50474057066,NDC,,,facility,both,1,UN,,48.2,36.15,,,,,,,,,,Gross Charge Type: Pharmacy
ATEZOLIZUMAB 1200 MG/20ML SOLN 20 ML VIAL,177226,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,both,10,ME,,233.35,175.01,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,1.3,ML,,39.85,29.89,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,1.4,ML,,41,30.75,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.9,ML,,70.55,52.91,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,1.9,ML,,46.7,35.02,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.45,ML,,53.9,40.42,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,3,ML,,39.53,29.65,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.3,ML,,44.18,33.14,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.5,ML,,57.15,42.86,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,4.4,ML,,30.13,22.6,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.75,ML,,67.1,50.32,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.65,ML,,64.8,48.6,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.8,ML,,68.25,51.19,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.81,ML,,68.5,51.38,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.55,ML,,60.35,45.26,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,4.6,ML,,31.06,23.3,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,51754420004,NDC,,,facility,both,0.8,ML,,68.25,51.19,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.05,ML,,28.25,21.19,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.6,ML,,63.55,47.66,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,51754420004,NDC,,,facility,both,0.5,ML,,57.15,42.86,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.15,ML,,34.65,25.99,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,1.5,ML,,42.12,31.59,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.35,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.02,ML,,26.3,19.72,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,51754420004,NDC,,,facility,both,0.2,ML,,37.85,28.39,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.7,ML,,65.95,49.46,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,51754420004,NDC,,,facility,both,1,ML,,72.85,54.64,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,51754420004,NDC,,,facility,both,0.1,ML,,31.45,23.59,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.2,ML,,37.76,28.32,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,2,ML,,47.85,35.89,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.85,ML,,69.4,52.05,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.1,ML,,31.45,23.59,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,1,ML,,72.85,54.64,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,1.6,ML,,43.28,32.46,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.4,ML,,50.61,37.95,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,2.5,ML,,35.72,26.79,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,0.25,ML,,41.1,30.82,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,1.8,ML,,45.55,34.16,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,1.1,ML,,37.58,28.18,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML SOLN,177354,CDM,250,RC,76014000525,NDC,,,facility,both,1.2,ML,,38.72,29.04,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE 2 MCG/ML-0.2% 0.2-0.2-0.9 MG/100ML-% SOLN,177377,CDM,636,RC,J7999,HCPCS,70092110836,NDC,facility,both,100,ML,,147.13,110.35,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE 2 MCG/ML-0.2% 0.2-0.2-0.9 MG/100ML-% SOLN,177377,CDM,636,RC,J7999,HCPCS,70092150436,NDC,facility,both,100,ML,,143.41,107.56,,,,,,,,,,Gross Charge Type: Pharmacy
PROBENECID 500 MG TABS,17744,CDM,250,RC,10135054101,NDC,,,facility,both,1,UN,,9.2,6.9,,,,,,,,,,Gross Charge Type: Pharmacy
PROBENECID 500 MG TABS,17744,CDM,250,RC,591534701,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML SOLN,17745,CDM,636,RC,J2690,HCPCS,409190201,NDC,facility,both,1,GM,,200.2,150.15,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML SOLN 10 ML VIAL,17745,CDM,636,RC,J2690,HCPCS,76329339905,NDC,facility,both,1,GM,,155.55,116.66,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML SOLN 10 ML VIAL,17745,CDM,636,RC,J2690,HCPCS,409190201,NDC,facility,both,1,GM,,189.31,141.98,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 2 MG/ML SOLR 1 EACH VIAL,177470,CDM,636,RC,J9047,HCPCS,76075010201,NDC,facility,both,1,ME,,161.9,121.43,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 12.5 MG CAPS,17759,CDM,250,RC,60687068311,NDC,,,facility,both,2,UN,,4.08,3.06,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 12.5 MG CAPS,17759,CDM,250,RC,29300013001,NDC,,,facility,both,4,UN,,2.12,1.59,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 12.5 MG CAPS,17759,CDM,250,RC,29300013001,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 12.5 MG CAPS,17759,CDM,250,RC,60687068311,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 12.5 MG CAPS,17759,CDM,250,RC,29300013001,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE 12.5 MG CAPS,17759,CDM,250,RC,60687068311,NDC,,,facility,both,4,UN,,2.28,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG TABS,17766,CDM,250,RC,68084009901,NDC,,,facility,both,2,UN,,4.8,3.6,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG TABS,17766,CDM,250,RC,904629261,NDC,,,facility,both,1,UN,,7.28,5.46,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG TABS,17766,CDM,250,RC,904629261,NDC,,,facility,both,0.125,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG TABS,17766,CDM,250,RC,60505258009,NDC,,,facility,both,1,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG TABS,17766,CDM,250,RC,904629261,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG TABS,17766,CDM,250,RC,60505258009,NDC,,,facility,both,0.5,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG TABS,17766,CDM,250,RC,68084009901,NDC,,,facility,both,1,UN,,8.53,6.4,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG TABS,17766,CDM,250,RC,60505258009,NDC,,,facility,both,2,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG TABS,17766,CDM,250,RC,904629261,NDC,,,facility,both,0.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG TABS,17780,CDM,250,RC,59746011506,NDC,,,facility,both,0.5,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG TABS,17780,CDM,250,RC,50268068515,NDC,,,facility,both,0.5,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG TABS,17780,CDM,250,RC,50268068515,NDC,,,facility,both,1,UN,,10.15,7.61,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG TABS,17780,CDM,250,RC,59746011506,NDC,,,facility,both,1,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 5 MG TABS,17782,CDM,250,RC,59746011306,NDC,,,facility,both,2,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 5 MG TABS,17782,CDM,250,RC,50268068415,NDC,,,facility,both,1,UN,,10,7.5,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 5 MG TABS,17782,CDM,250,RC,59746011306,NDC,,,facility,both,1,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 5 MG TABS,17782,CDM,250,RC,50268068415,NDC,,,facility,both,2,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE 5 MG/ML (0.5 %) SOLN,178175,CDM,636,RC,Q9968,HCPCS,517037405,NDC,facility,both,1,ME,,14.35,10.76,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50-325-40 MG TABS,17842,CDM,250,RC,904693806,NDC,,,facility,both,2,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50-325-40 MG TABS,17842,CDM,250,RC,60687067265,NDC,,,facility,both,1,UN,,9.86,7.4,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50-325-40 MG TABS,17842,CDM,250,RC,60687067265,NDC,,,facility,both,2,UN,,6.02,4.52,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50-325-40 MG TABS,17842,CDM,250,RC,904693806,NDC,,,facility,both,1,UN,,10.5,7.88,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 20 MG/ACT SOLN,17844,CDM,250,RC,MHS20MG,HCPCS,527185943,NDC,facility,both,20,ME,,88.05,66.04,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN PEDIATRIC SOLN 5 ML VIAL,178778,CDM,250,RC,54643564601,NDC,,,facility,both,5,ML,,85.4,64.05,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN PEDIATRIC SOLN 5 ML VIAL,178778,CDM,250,RC,54643564601,NDC,,,facility,both,1.5,ML,,54.85,41.14,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN PEDIATRIC SOLN 5 ML VIAL,178778,CDM,250,RC,54643564601,NDC,,,facility,both,3.3,ML,,73.35,55.01,,,,,,,,,,Gross Charge Type: Pharmacy
USTEKINUMAB 130 MG/26ML SOLN 26 ML VIAL,178795,CDM,636,RC,J3358,HCPCS,57894005427,NDC,facility,both,1,ME,,36.9,27.67,,,,,,,,,,Gross Charge Type: Pharmacy
ANAGRELIDE 0.5 MG CAPS,17885,CDM,250,RC,172524160,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML SOLN,17886,CDM,636,RC,J2550,HCPCS,39822552503,NDC,facility,both,50,ME,,33.65,25.24,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML SOLN,17886,CDM,636,RC,J2550,HCPCS,641608425,NDC,facility,both,50,ME,,35.68,26.76,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML SOLN,17886,CDM,636,RC,J2550,HCPCS,641149535,NDC,facility,both,50,ME,,35.82,26.86,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML SOLN,17886,CDM,636,RC,J2550,HCPCS,641092825,NDC,facility,both,50,ME,,35.68,26.76,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML SOLN 1 ML AMPULE,17886,CDM,636,RC,J2550,HCPCS,39822552503,NDC,facility,both,50,ME,,30.9,23.18,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML SOLN 1 ML AMPULE,17886,CDM,636,RC,J2550,HCPCS,641149535,NDC,facility,both,50,ME,,33.17,24.88,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML SOLN 1 ML VIAL,17886,CDM,636,RC,J2550,HCPCS,641092825,NDC,facility,both,50,ME,,36.8,27.6,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML SOLN 1 ML VIAL,17886,CDM,636,RC,J2550,HCPCS,641608425,NDC,facility,both,50,ME,,34.57,25.93,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE HCL 25 MG/ML IJ SOLN,17886,CDM,641608225,NDC,,,,,facility,both,50,ML,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE HCL 25 MG/ML IJ SOLN,17886,CDM,641092825,NDC,,,,,facility,both,50,ML,,18.06,13.54,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE HCL 25 MG/ML IJ SOLN,17886,CDM,641092821,NDC,,,,,facility,both,50,ML,,14.93,11.2,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 50 MG/ML SOLN,17887,CDM,636,RC,J2550,HCPCS,641092925,NDC,facility,both,50,ME,,34.28,25.71,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 50 MG/ML SOLN,17887,CDM,636,RC,J2550,HCPCS,641149635,NDC,facility,both,50,ME,,31.22,23.42,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 50 MG/ML SOLN 1 ML VIAL,17887,CDM,636,RC,J2550,HCPCS,641092925,NDC,facility,both,50,ME,,30.23,22.67,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE HCL 50 MG/ML IJ SOLN,17887,CDM,641092925,NDC,,,,,facility,both,50,ML,,12.85,9.63,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG TABS,17890,CDM,250,RC,53746074501,NDC,,,facility,both,4,UN,,2.01,1.51,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG TABS,17890,CDM,250,RC,65162074510,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG TABS,17890,CDM,250,RC,53746074501,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG TABS,17890,CDM,250,RC,53746074501,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG TABS,17890,CDM,250,RC,53746074501,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG TABS,17891,CDM,250,RC,904730461,NDC,,,facility,both,0.5,UN,,6.41,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG TABS,17891,CDM,250,RC,904730461,NDC,,,facility,both,5,UN,,1.77,1.33,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG TABS,17891,CDM,250,RC,68084015501,NDC,,,facility,both,0.5,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG TABS,17891,CDM,250,RC,904730461,NDC,,,facility,both,1,UN,,6.78,5.08,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG TABS,17891,CDM,250,RC,904730461,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG TABS,17891,CDM,250,RC,68084015501,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE-CODEINE 6.25-10 MG/5ML SYRP,17900,CDM,250,RC,MHS1ML,HCPCS,60432060616,NDC,facility,both,1,ML,,1.14,0.85,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG SOLR 1 EACH VIAL,179045,CDM,636,RC,Q5103,HCPCS,69080901,NDC,facility,both,10,ME,,109.16,81.87,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 19.5 MG IU IUD,179124,CDM,50419042401,NDC,,,,,facility,both,1,EA,,1875.59,1406.69,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 19.5 MG IUD,179124,CDM,636,RC,J7296,HCPCS,50419042401,NDC,facility,both,1,EA,,1978.38,1483.78,,,,,,,,,,Gross Charge Type: Pharmacy
BEZLOTOXUMAB 1000 MG/40ML SOLN 40 ML VIAL,179359,CDM,636,RC,J0565,HCPCS,6302500,NDC,facility,both,10,ME,,93.29,69.96,,,,,,,,,,Gross Charge Type: Pharmacy
PROPARACAINE 0.5 % SOLN 15 ML BOTTLE,17948,CDM,250,RC,MHS1ML,HCPCS,24208073006,NDC,facility,both,1,ML,,5.33,4,,,,,,,,,,Gross Charge Type: Pharmacy
PROPARACAINE 0.5 % SOLN 15 ML BOTTLE,17948,CDM,250,RC,MHS1ML,HCPCS,61314001601,NDC,facility,both,1,ML,,5.48,4.11,,,,,,,,,,Gross Charge Type: Pharmacy
UREA 15 G PACK,179578,CDM,250,RC,62530000011,NDC,,,facility,both,2,UN,,10.55,7.91,,,,,,,,,,Gross Charge Type: Pharmacy
UREA 15 G PACK,179578,CDM,250,RC,62530000011,NDC,,,facility,both,1,UN,,14.9,11.18,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,69238207701,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,60687058701,NDC,,,facility,both,4,UN,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,60687058701,NDC,,,facility,both,2,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,69238207701,NDC,,,facility,both,4,UN,,2.26,1.7,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,378018201,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,60687058701,NDC,,,facility,both,1,UN,,7.5,5.63,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,378018201,NDC,,,facility,both,1,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,60687058701,NDC,,,facility,both,3,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,69238207701,NDC,,,facility,both,2,UN,,4.02,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,69238207701,NDC,,,facility,both,3,UN,,2.9,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 10 MG TABS,17970,CDM,250,RC,378018201,NDC,,,facility,both,4,UN,,2.54,1.9,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG TABS,17971,CDM,250,RC,603548321,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG TABS,17971,CDM,250,RC,603548321,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG TABS,17971,CDM,250,RC,60687059801,NDC,,,facility,both,3,UN,,3.42,2.56,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG TABS,17971,CDM,250,RC,60687059801,NDC,,,facility,both,2,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG TABS,17971,CDM,250,RC,60687059801,NDC,,,facility,both,4,UN,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG TABS,17971,CDM,250,RC,60687059801,NDC,,,facility,both,1,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG TABS,17971,CDM,250,RC,603548321,NDC,,,facility,both,2,UN,,3.92,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG TABS,17971,CDM,250,RC,60687059801,NDC,,,facility,both,0.5,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 40 MG TABS,17972,CDM,250,RC,60687060901,NDC,,,facility,both,4,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 40 MG TABS,17972,CDM,250,RC,60687060901,NDC,,,facility,both,3,UN,,3.77,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 40 MG TABS,17972,CDM,250,RC,591555601,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 40 MG TABS,17972,CDM,250,RC,60687060901,NDC,,,facility,both,0.5,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 40 MG TABS,17972,CDM,250,RC,60687060901,NDC,,,facility,both,1.5,UN,,4.75,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 40 MG TABS,17972,CDM,250,RC,591555601,NDC,,,facility,both,1,UN,,8.53,6.4,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 40 MG TABS,17972,CDM,250,RC,60687060901,NDC,,,facility,both,2,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 40 MG TABS,17972,CDM,250,RC,591555601,NDC,,,facility,both,0.5,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 40 MG TABS,17972,CDM,250,RC,60687060901,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG TABS,17979,CDM,250,RC,68084096425,NDC,,,facility,both,2,UN,,8.42,6.32,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG TABS,17979,CDM,250,RC,67253065110,NDC,,,facility,both,0.5,UN,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG TABS,17979,CDM,250,RC,67253065110,NDC,,,facility,both,2,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML SOLN,18006,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,both,10,ME,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML SOLN,18006,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,both,10,ME,,9.08,6.81,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML SOLN 5 ML VIAL,18006,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,both,10,ME,,14.81,11.11,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 30 UNITS IN 500 ML NS 30-0.9 UT/500ML-% SOLN,180318,CDM,636,RC,J2590,HCPCS,70092155207,NDC,facility,both,10,UN,,33.51,25.13,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 30 UNITS IN 500 ML NS 30-0.9 UT/500ML-% SOLN,180318,CDM,636,RC,J2590,HCPCS,70092106807,NDC,facility,both,10,UN,,33.53,25.15,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % AERO,180376,CDM,250,RC,283067902,NDC,,,facility,both,57,GR,,85.05,63.79,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % AERO 57 G CAN,180376,CDM,250,RC,283067902,NDC,,,facility,both,57,GR,,82.89,62.17,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 50 MCG/ML SOSY,180377,CDM,636,RC,J0476,HCPCS,66794015101,NDC,facility,both,1,ML,,242.25,181.69,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10000 MCG/20 ML SOSY,180378,CDM,636,RC,J0475,HCPCS,66794015502,NDC,facility,both,10,ME,,523,392.25,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10000 MCG/20 ML SOSY,180378,CDM,636,RC,J0475,HCPCS,66794015501,NDC,facility,both,10,ME,,474.75,356.06,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10000 MCG/20ML IT SOSY,180378,CDM,66794015501,NDC,,,,,facility,both,10,ML,,474.75,356.06,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20000 MCG/20 ML SOSY,180379,CDM,636,RC,J0475,HCPCS,66794015601,NDC,facility,both,10,ME,,425.9,319.42,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20000 MCG/20ML IT SOSY,180379,CDM,66794015601,NDC,,,,,facility,both,10,ML,,420.97,315.73,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 40000 MCG/20 ML SOSY,180380,CDM,636,RC,J0475,HCPCS,66794015701,NDC,facility,both,10,ME,,355.91,266.93,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 40000 MCG/20ML IT SOSY,180380,CDM,66794015701,NDC,,,,,facility,both,10,ML,,346.74,260.06,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML SOLN 15 ML VIAL,180383,CDM,250,RC,MHS1ML,HCPCS,63323088101,NDC,facility,both,1,ML,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML SOLN 15 ML VIAL,180383,CDM,250,RC,MHS1ML,HCPCS,409739182,NDC,facility,both,1,ML,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML SOLN 15 ML VIAL,180383,CDM,250,RC,MHS1ML,HCPCS,63323088116,NDC,facility,both,1,ML,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML SOLN 5 ML VIAL,180383,CDM,250,RC,MHS1ML,HCPCS,63323088406,NDC,facility,both,1,ML,,12.01,9.01,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML SOLN 5 ML VIAL,180383,CDM,250,RC,MHS1ML,HCPCS,63323017005,NDC,facility,both,1,ML,,10.93,8.2,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN DEXTROSE 5% 1-5 GM/100ML-% SOLN,180385,CDM,636,RC,J3475,HCPCS,409672723,NDC,facility,both,500,ME,,30.42,22.82,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN DEXTROSE 5% 1-5 GM/100ML-% SOLN,180385,CDM,636,RC,J3475,HCPCS,338170940,NDC,facility,both,500,ME,,25.18,18.88,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN DEXTROSE 5% 1-5 GM/100ML-% SOLN,180385,CDM,636,RC,J3475,HCPCS,264440054,NDC,facility,both,500,ME,,27.05,20.29,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN DEXTROSE 5% 1-5 GM/100ML-% SOLN,180385,CDM,636,RC,J3475,HCPCS,44567041024,NDC,facility,both,500,ME,,25.8,19.35,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN DEXTROSE 5% 1-5 GM/100ML-% SOLN,180385,CDM,636,RC,J3475,HCPCS,67457056700,NDC,facility,both,500,ME,,26.75,20.06,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 80 MG/ML SUSP,180393,CDM,250,RC,MHS1ML,HCPCS,10122051003,NDC,facility,both,1,ML,,484.41,363.31,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML SOSY,180398,CDM,636,RC,J0461,HCPCS,409491034,NDC,facility,both,0.01,ME,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML SOSY,180399,CDM,636,RC,J0461,HCPCS,409491134,NDC,facility,both,0.01,ME,,0.7,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML SOSY,180399,CDM,636,RC,J0461,HCPCS,76329334001,NDC,facility,both,0.01,ME,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML SOSY,180399,CDM,636,RC,J0461,HCPCS,409163010,NDC,facility,both,0.01,ME,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE SULFATE 1 MG/10ML IJ SOSY,180399,CDM,409491134,NDC,,,,,facility,both,0.01,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE SULFATE 1 MG/10ML IJ SOSY,180399,CDM,409163010,NDC,,,,,facility,both,0.01,ML,,0.65,0.49,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 2 GM/20ML SOSY,180452,CDM,636,RC,J0690,HCPCS,70092160447,NDC,facility,both,500,ME,,19.46,14.6,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 2 GM/20ML SOSY,180452,CDM,636,RC,J0690,HCPCS,66288130001,NDC,facility,both,500,ME,,19.89,14.92,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 2 GM/20ML SOSY,180452,CDM,636,RC,J0690,HCPCS,66288110001,NDC,facility,both,500,ME,,8.64,6.48,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 2 GM/20ML SOSY,180452,CDM,636,RC,J0690,HCPCS,70092123847,NDC,facility,both,500,ME,,19.46,14.6,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG/10.15ML SOLN,180458,CDM,250,RC,81033000230,NDC,,,facility,both,10.15625,ML,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG/10.15ML SOLN,180458,CDM,250,RC,81033000230,NDC,,,facility,both,20.3125,ML,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG/10.15ML SOLN,180458,CDM,250,RC,81033000230,NDC,,,facility,both,20.3,ML,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG/10.15ML SOLN,180458,CDM,250,RC,81033000230,NDC,,,facility,both,31.25,ML,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE 72 MCG CAPS,180476,CDM,250,RC,456120330,NDC,,,facility,both,1,UN,,36.35,27.26,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 51.7 % PACK,180626,CDM,250,RC,37000002404,NDC,,,facility,both,1,UN,,8.31,6.23,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 51.7 % PACK,180626,CDM,250,RC,37000002404,NDC,,,facility,both,2,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE 100 MG/ML SOLN 5 ML VIAL,18078,CDM,250,RC,MHS1ML,HCPCS,63323049405,NDC,facility,both,1,ML,,13.39,10.04,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE 100 MG/ML SOLN 5 ML VIAL,18078,CDM,250,RC,MHS1ML,HCPCS,143978510,NDC,facility,both,1,ML,,7.98,5.98,,,,,,,,,,Gross Charge Type: Pharmacy
AVELUMAB 20 MG/ML SOLN 10 ML VIAL,180829,CDM,636,RC,J9023,HCPCS,44087353501,NDC,facility,both,10,ME,,252.48,189.36,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TABS,18088,CDM,250,RC,904699061,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TABS,18088,CDM,250,RC,904699061,NDC,,,facility,both,2,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TABS,18088,CDM,250,RC,904505359,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20-5 MG/100ML-% SOLN,180901,CDM,636,RC,J2260,HCPCS,409277623,NDC,facility,both,5,ME,,23.08,17.31,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20-5 MG/100ML-% SOLN,180901,CDM,636,RC,J2260,HCPCS,143971910,NDC,facility,both,5,ME,,18.39,13.79,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20-5 MG/100ML-% SOLN,180901,CDM,636,RC,J2260,HCPCS,338601048,NDC,facility,both,5,ME,,23.79,17.84,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20-5 MG/100ML-% SOLN 100 ML FLEX CONT,180901,CDM,636,RC,J2260,HCPCS,409277623,NDC,facility,both,5,ME,,23.45,17.59,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20-5 MG/100ML-% SOLN 100 ML FLEX CONT,180901,CDM,636,RC,J2260,HCPCS,338601048,NDC,facility,both,5,ME,,23.79,17.84,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 10 % SOLN,180902,CDM,250,RC,17478025310,NDC,,,facility,both,0.25,ML,,144.6,108.45,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 10 % SOLN,180902,CDM,250,RC,65009265,NDC,,,facility,both,1,ML,,172.45,129.34,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 10 % SOLN,180902,CDM,250,RC,65009265,NDC,,,facility,both,0.0025,ML,,172.45,129.34,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 10 % SOLN,180902,CDM,250,RC,65009265,NDC,,,facility,both,2.5,ML,,172.45,129.34,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 10 % SOLN,180902,CDM,250,RC,65009265,NDC,,,facility,both,0.25,ML,,172.45,129.34,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 10 % SOLN,180902,CDM,250,RC,14789012207,NDC,,,facility,both,0.25,ML,,76,57,,,,,,,,,,Gross Charge Type: Pharmacy
L-CARNITINE 200 MG/ML SOLN,18091,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,both,1,GM,,102.62,76.96,,,,,,,,,,Gross Charge Type: Pharmacy
L-CARNITINE 200 MG/ML SOLN,18091,CDM,636,RC,J1955,HCPCS,143985201,NDC,facility,both,1,GM,,86.93,65.2,,,,,,,,,,Gross Charge Type: Pharmacy
DUPILUMAB 300 MG/2 ML SOSY,180927,CDM,636,RC,C9399,HCPCS,24591401,NDC,facility,both,1,EA,,3836.99,2877.74,,,,,,,,,,Gross Charge Type: Pharmacy
OCRELIZUMAB 300 MG/10ML SOLN 10 ML VIAL,180928,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,both,1,ME,,157.52,118.14,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG KIT,18111,CDM,636,RC,J9217,HCPCS,74334603,NDC,facility,both,7.5,ME,,5254.86,3941.14,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN SOLR 1 EACH VIAL,18132,CDM,636,RC,J0456,HCPCS,63323039810,NDC,facility,both,500,ME,,68.8,51.6,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN SOLR 1 EACH VIAL,18132,CDM,636,RC,J0456,HCPCS,69315083,NDC,facility,both,500,ME,,65.4,49.05,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN SOLR 1 EACH VIAL,18132,CDM,636,RC,J0456,HCPCS,55150017410,NDC,facility,both,500,ME,,43.23,32.42,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 2 MG/2ML SOSY,181371,CDM,636,RC,69374092203,NDC,,,facility,both,2,ML,,91.05,68.29,,,,,,,,,,Gross Charge Type: Pharmacy
XYLITOL 550 MG DISK,181447,CDM,250,RC,55933000051,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
GENTEAL TEARS NIGHT-TIME OINT 3.5 G TUBE,181582,CDM,250,RC,65051801,NDC,,,facility,both,3.5,GR,,36.5,27.38,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE HYDROCHLORIDE 100 MG/ML SOLN,18159,CDM,636,RC,J3415,HCPCS,63323018001,NDC,facility,both,100,ME,,69.5,52.12,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE HYDROCHLORIDE 100 MG/ML SOLN 1 ML VIAL,18159,CDM,636,RC,J3415,HCPCS,63323018001,NDC,facility,both,100,ME,,36.3,27.22,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB 21 MG/ML SOLR 1 EACH VIAL,181724,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,both,10,ME,,299.99,224.99,,,,,,,,,,Gross Charge Type: Pharmacy
ABIRATERONE 500 MG TABS,181737,CDM,250,RC,378692191,NDC,,,facility,both,2,UN,,673.28,504.96,,,,,,,,,,Gross Charge Type: Pharmacy
ABIRATERONE 500 MG TABS,181737,CDM,250,RC,57894019506,NDC,,,facility,both,2,UN,,760.95,570.71,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN NS 600 MG/50 ML SOLN,181766,CDM,250,RC,338954924,NDC,,,facility,both,300,ME,,60.4,45.3,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN NS 600 MG/50 ML SOLN,181766,CDM,636,RC,J0737,HCPCS,338954924,NDC,facility,both,300,ME,,29.46,22.1,,,,,,,,,,Gross Charge Type: Pharmacy
MIDOSTAURIN 25 MG CAPS,181783,CDM,250,RC,78069899,NDC,,,facility,both,2,UN,,751.43,563.57,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML SOLN 10 ML VIAL,181790,CDM,636,RC,J9173,HCPCS,310461150,NDC,facility,both,10,ME,,213.65,160.24,,,,,,,,,,Gross Charge Type: Pharmacy
HEMIN 350 MG SOLR,182269,CDM,636,RC,J1640,HCPCS,55292070255,NDC,facility,both,1,ME,,73.37,55.02,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE 2500 MCG/50ML SOLN,182422,CDM,250,RC,70092150935,NDC,,,facility,both,50,ML,,99.45,74.59,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE 2500 MCG/50ML SOLN,182422,CDM,250,RC,70092150935,NDC,,,facility,both,100,ML,,82.45,61.84,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE 2500 MCG/50ML SOLN,182422,CDM,250,RC,70092122335,NDC,,,facility,both,50,ML,,196.65,147.49,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 GM/10ML SOSY,182423,CDM,636,RC,J0690,HCPCS,70092160447,NDC,facility,both,500,ME,,31.95,23.96,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 GM/10ML SOSY,182423,CDM,636,RC,J0690,HCPCS,66288130001,NDC,facility,both,500,ME,,37.09,27.82,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 GM/10ML SOSY,182423,CDM,636,RC,J0690,HCPCS,70092160346,NDC,facility,both,500,ME,,37.3,27.98,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 GM/10ML SOSY,182423,CDM,636,RC,J0690,HCPCS,70092101746,NDC,facility,both,500,ME,,34.67,26,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 GM/10ML SOSY,182423,CDM,636,RC,70092160346,NDC,,,facility,both,500,ME,,74.6,55.95,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG SOLR 1 EACH VIAL,182433,CDM,636,RC,Q5104,HCPCS,78206016201,NDC,facility,both,10,ME,,94.54,70.91,,,,,,,,,,Gross Charge Type: Pharmacy
SOD BICARB-K BICARB-CITRIC ACID 1050-344-1000 MG TBEF,182448,CDM,250,RC,16500056675,NDC,,,facility,both,2,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN-CYTARABINE LIPOSOMAL 44-100 MG SUSR 1 EACH VIAL,182689,CDM,636,RC,J9153,HCPCS,68727074501,NDC,facility,both,1,ME,,611.05,458.29,,,,,,,,,,Gross Charge Type: Pharmacy
QUINIDINE SULFATE 200 MG TABS,18274,CDM,250,RC,42806051330,NDC,,,facility,both,2,UN,,24.3,18.22,,,,,,,,,,Gross Charge Type: Pharmacy
QUINIDINE SULFATE 200 MG TABS,18274,CDM,250,RC,42806051330,NDC,,,facility,both,1,UN,,29.55,22.16,,,,,,,,,,Gross Charge Type: Pharmacy
QUINIDINE SULFATE 200 MG TABS,18274,CDM,250,RC,42806051330,NDC,,,facility,both,1.5,UN,,19.55,14.66,,,,,,,,,,Gross Charge Type: Pharmacy
INOTUZUMAB OZOGAMICIN 0.9 MG SOLR 1 EACH VIAL,182781,CDM,636,RC,J9229,HCPCS,8010001,NDC,facility,both,0.1,ME,,6403.27,4802.45,,,,,,,,,,Gross Charge Type: Pharmacy
C TDAP IM (ADACEL) 19-64 YRS 90715,182950,CDM,636,RC,90715,HCPCS,49281028610,NDC,facility,both,1,EA,,60,45,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE 15-23-5 LF-MCG/0.5 SUSP",182950,CDM,636,RC,90700,HCPCS,49281028610,NDC,facility,both,1,EA,,111.05,83.29,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1.5 % SOLN,182960,CDM,250,RC,63323049397,NDC,,,facility,both,6.666666667,ML,,54.7,41.02,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1.5 % SOLN,182960,CDM,250,RC,63323049397,NDC,,,facility,both,10,ML,,65.8,49.35,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE PRESERVATIVE FREE 1.5 % SOLN,182960,CDM,250,RC,63323049397,NDC,,,facility,both,7,ML,,56.2,42.15,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE 0.5 % SOLN,182965,CDM,250,RC,23040330,NDC,,,facility,both,1,UN,,24.45,18.34,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE 0.5 % SOLN,182965,CDM,250,RC,23040330,NDC,,,facility,both,4,UN,,6.59,4.94,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE 0.5 % SOLN,182965,CDM,250,RC,23040330,NDC,,,facility,both,2,UN,,12.58,9.43,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE ER 300 MG PRSY,182968,CDM,636,RC,J0401,HCPCS,59148004580,NDC,facility,both,1,ME,,11.37,8.53,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE ER 400 MG IM PRSY,182969,CDM,59148007280,NDC,,,,,facility,both,1,EA,,10.74,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE PF 1 MG/ML IJ SOLN,182977,CDM,42023015925,NDC,,,,,facility,both,0.1,ML,,13.75,10.31,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE PF 1 MG/ML IJ SOLN,182977,CDM,54288010310,NDC,,,,,facility,both,0.1,ML,,12.87,9.65,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE PF 1 MG/ML IJ SOLN,182977,CDM,54288010310,NDC,,,,,facility,both,0.1,ML,,2.5,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE PF 1 MG/ML SOLN,182977,CDM,636,RC,J0173,HCPCS,54288010310,NDC,facility,both,0.1,ME,,4.67,3.5,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE PF 1 MG/ML SOLN,182977,CDM,636,RC,J0171,HCPCS,54288010310,NDC,facility,both,0.1,ME,,4.95,3.71,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE,182977,CDM,636,RC,J0173,HCPCS,54288010310,NDC,facility,both,0.1,ME,,4.58,3.44,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE PF 1 MG/ML SOLN 1 ML AMPULE,182977,CDM,636,RC,J0171,HCPCS,54288010310,NDC,facility,both,0.1,ME,,4.11,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN,183109,CDM,42023015925,NDC,,,,,facility,both,0.1,ML,,6.17,4.63,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN,183109,CDM,54288010310,NDC,,,,,facility,both,0.1,ML,,12.72,9.54,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML SOLN,183109,CDM,636,RC,J0171,HCPCS,42023015925,NDC,facility,both,0.1,ME,,20.5,15.38,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML SOLN 1 ML VIAL,183109,CDM,636,RC,J0171,HCPCS,42023015925,NDC,facility,both,0.1,ME,,6.55,4.92,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML SOLN 30 ML VIAL,183109,CDM,636,RC,J0171,HCPCS,42023016801,NDC,facility,both,0.1,ME,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
ZOSTER VAC RECOMB ADJUVANTED 50 MCG/0.5ML IM SUSR,183416,CDM,58160082803,NDC,,,,,facility,both,0.5,EA,,65,48.75,,,,,,,,,,Gross Charge Type: Pharmacy
ZOSTER VAC RECOMB ADJUVANTED 50 MCG/0.5ML IM SUSR,183416,CDM,58160082803,NDC,,,,,facility,both,0.5,EA,,214,160.5,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN,183419,CDM,250,RC,49230020650,NDC,,,facility,both,4000,ML,,46.75,35.06,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN,183419,CDM,250,RC,49230020692,NDC,,,facility,both,2000,ML,,29.15,21.86,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN,183419,CDM,250,RC,49230020692,NDC,,,facility,both,1000,ML,,26.2,19.65,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN,183419,CDM,250,RC,49230020650,NDC,,,facility,both,3000,ML,,39.95,29.96,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN,183419,CDM,250,RC,49230020650,NDC,,,facility,both,1000,ML,,25.35,19.01,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN,183419,CDM,250,RC,49230020650,NDC,,,facility,both,5000,ML,,53.55,40.16,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN 2,000 ML FLEX CONT",183419,CDM,250,RC,49230020692,NDC,,,facility,both,3000,ML,,17.3,12.98,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN 2,000 ML FLEX CONT",183419,CDM,250,RC,49230020692,NDC,,,facility,both,2000,ML,,29.15,21.86,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN 5,000 ML FLEX CONT",183419,CDM,250,RC,49230020650,NDC,,,facility,both,1000,ML,,25.35,19.01,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN 5,000 ML FLEX CONT",183419,CDM,250,RC,941040907,NDC,,,facility,both,5000,ML,,70.5,52.88,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN 5,000 ML FLEX CONT",183419,CDM,250,RC,49230020650,NDC,,,facility,both,300,ML,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 1.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 344 MOSM/L SOLN 5,000 ML FLEX CONT",183419,CDM,250,RC,49230020650,NDC,,,facility,both,5000,ML,,53.55,40.16,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 30 MG/30ML SOLN,183526,CDM,636,RC,J0171,HCPCS,42023016801,NDC,facility,both,0.1,ME,,2.14,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 30 MG/30ML SOLN 30 ML VIAL,183526,CDM,636,RC,J0171,HCPCS,42023016801,NDC,facility,both,0.1,ME,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
BENRALIZUMAB 30 MG/ML SOSY,183565,CDM,636,RC,J0517,HCPCS,310173030,NDC,facility,both,1,ME,,404.17,303.13,,,,,,,,,,Gross Charge Type: Pharmacy
FIBRINOGEN/APROTININ AND THROMBIN/CACL SOLN,183710,CDM,250,RC,338956401,NDC,,,facility,both,4,ML,,348.85,261.64,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE 40 MCG/ACT AERB 10.6 G INHALER,183718,CDM,250,RC,59310030240,NDC,,,facility,both,10.6,GR,,304.35,228.26,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE 80 MCG/ACT AERB 10.6 G INHALER,183719,CDM,250,RC,59310030480,NDC,,,facility,both,10.6,GR,,398.55,298.91,,,,,,,,,,Gross Charge Type: Pharmacy
ANGIOTENSIN II ACETATE 2.5 MG/ML SOLN 1 ML VIAL,184001,CDM,636,RC,C9399,HCPCS,68547050102,NDC,facility,both,1,EA,,3721.46,2791.1,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 10 MG/ML SOLN 24 ML VIAL,184019,CDM,636,RC,J9299,HCPCS,3373413,NDC,facility,both,1,ME,,82.82,62.12,,,,,,,,,,Gross Charge Type: Pharmacy
BICTEGRAVIR-EMTRICITABINE-TENOFOVIR 50-200-25 MG TABS,184392,CDM,250,RC,61958250101,NDC,,,facility,both,1,UN,,200.45,150.34,,,,,,,,,,Gross Charge Type: Pharmacy
CLEVIDIPINE 0.5 MG/ML EMUL,184765,CDM,636,RC,C9248,HCPCS,10122061010,NDC,facility,both,1,ME,,10.41,7.81,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG/5ML SOLR 1 EACH VIAL,184771,CDM,636,RC,J0583,HCPCS,55111065237,NDC,facility,both,1,ME,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG/5ML SOLR 1 EACH VIAL,184771,CDM,636,RC,J0583,HCPCS,781315895,NDC,facility,both,1,ME,,0.96,0.72,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG/5ML SOLR 1 EACH VIAL,184771,CDM,636,RC,J0583,HCPCS,63323056210,NDC,facility,both,1,ME,,1.72,1.29,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 5 MG/ML SOLR,184771,CDM,636,RC,J0583,HCPCS,63323056210,NDC,facility,both,1,ME,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 5 MG/ML SOLR 1 EACH VIAL,184771,CDM,636,RC,J0583,HCPCS,55111065237,NDC,facility,both,1,ME,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 5 MG/ML SOLR 1 EACH VIAL,184771,CDM,636,RC,J0583,HCPCS,781315895,NDC,facility,both,1,ME,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 5 MG/ML SOLR 1 EACH VIAL,184771,CDM,636,RC,J0583,HCPCS,63323056210,NDC,facility,both,1,ME,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
TALC 4 G POWD,185193,CDM,250,RC,62327044404,NDC,,,facility,both,1,UN,,131.6,98.7,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (HUMAN) 300 UNIT/ML SOLN,185234,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,both,150,UN,,605.35,454.01,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 500 MG/10ML SOLN 10 ML VIAL,185280,CDM,636,RC,J1570,HCPCS,25021018510,NDC,facility,both,500,ME,,141.25,105.94,,,,,,,,,,Gross Charge Type: Pharmacy
BUROSUMAB-TWZA 20 MG/ML SOLN,185314,CDM,636,RC,J0584,HCPCS,69794020301,NDC,facility,both,1,ME,,1014.95,761.21,,,,,,,,,,Gross Charge Type: Pharmacy
BUROSUMAB-TWZA 20 MG/ML SOLN,185314,CDM,636,RC,J0584,HCPCS,42747020301,NDC,facility,both,1,ME,,1045.39,784.04,,,,,,,,,,Gross Charge Type: Pharmacy
BUROSUMAB-TWZA 20 MG/ML SOLN 1 ML VIAL,185314,CDM,636,RC,J0584,HCPCS,69794020301,NDC,facility,both,1,ME,,1014.95,761.21,,,,,,,,,,Gross Charge Type: Pharmacy
BUROSUMAB-TWZA 20 MG/ML SOLN 1 ML VIAL,185314,CDM,636,RC,J0584,HCPCS,42747020301,NDC,facility,both,1,ME,,1045.39,784.04,,,,,,,,,,Gross Charge Type: Pharmacy
BUROSUMAB-TWZA 30 MG/ML SOLN,185315,CDM,636,RC,J0584,HCPCS,69794030401,NDC,facility,both,1,ME,,1014.95,761.21,,,,,,,,,,Gross Charge Type: Pharmacy
BUROSUMAB-TWZA 30 MG/ML SOLN,185315,CDM,636,RC,J0584,HCPCS,42747030401,NDC,facility,both,1,ME,,1045.39,784.04,,,,,,,,,,Gross Charge Type: Pharmacy
BUROSUMAB-TWZA 30 MG/ML SOLN 1 ML VIAL,185315,CDM,636,RC,J0584,HCPCS,42747030401,NDC,facility,both,1,ME,,1045.39,784.04,,,,,,,,,,Gross Charge Type: Pharmacy
BUROSUMAB-TWZA 30 MG/ML SOLN 1 ML VIAL,185315,CDM,636,RC,J0584,HCPCS,69794030401,NDC,facility,both,1,ME,,1014.85,761.13,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID 25000 MG/50ML SOLN 50 ML VIAL,185574,CDM,250,RC,67157010151,NDC,,,facility,both,1,ML,,60.15,45.11,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID 25000 MG/50ML SOLN 50 ML VIAL,185574,CDM,250,RC,67157010151,NDC,,,facility,both,0.6,ML,,46.1,34.58,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 4,000 UNITS/ML SOLN",185689,CDM,636,RC,Q5106,HCPCS,69130710,NDC,facility,both,1000,UN,,30.88,23.16,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,185689,CDM,69130701,NDC,,,,,facility,both,1000,ML,,26,19.5,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 10,000 UNITS/ML SOLN",185690,CDM,636,RC,Q5106,HCPCS,69130810,NDC,facility,both,1000,UN,,34.32,25.74,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 10,000 UNITS/ML SOLN 1 ML VIAL",185690,CDM,636,RC,Q5106,HCPCS,69130810,NDC,facility,both,1000,UN,,41.21,30.91,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,185690,CDM,69130810,NDC,,,,,facility,both,1000,ML,,33.75,25.31,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,185690,CDM,69130801,NDC,,,,,facility,both,1000,ML,,26,19.5,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 40,000 UNITS/ML SOLN",185691,CDM,636,RC,Q5106,HCPCS,69130904,NDC,facility,both,1000,UN,,30.92,23.19,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF) 4 MG/ML SOLN,185774,CDM,636,RC,J2272,HCPCS,63323045401,NDC,facility,both,10,ME,,41.05,30.79,,,,,,,,,,Gross Charge Type: Pharmacy
BARICITINIB 2 MG TABS,185984,CDM,250,RC,2418230,NDC,,,facility,both,2,UN,,134.1,100.58,,,,,,,,,,Gross Charge Type: Pharmacy
BARICITINIB 2 MG TABS,185984,CDM,250,RC,2418230,NDC,,,facility,both,1,UN,,145.25,108.94,,,,,,,,,,Gross Charge Type: Pharmacy
BARICITINIB 2 MG TABS,185984,CDM,250,RC,2418230,NDC,,,facility,both,0.5,UN,,80.2,60.15,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,186073,CDM,636,RC,J1644,HCPCS,63323051877,NDC,facility,both,1000,UN,,4.49,3.37,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,186073,CDM,636,RC,J1644,HCPCS,63323052277,NDC,facility,both,1000,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,186073,CDM,636,RC,J1644,HCPCS,63323051801,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,186073,CDM,636,RC,J1644,HCPCS,409315020,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-JMDB 6 MG/0.6ML SOSY,186249,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,both,0.5,ME,,340.82,255.62,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-JMDB 6 MG/0.6ML SOSY,186249,CDM,636,RC,Q5108,HCPCS,83257000541,NDC,facility,both,0.5,ME,,357.07,267.8,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 2 MG/ML SOLR 1 EACH VIAL,186472,CDM,636,RC,J9047,HCPCS,76075010301,NDC,facility,both,1,ME,,173.32,129.99,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/10ML SOSY,186474,CDM,636,RC,J0171,HCPCS,409492134,NDC,facility,both,0.1,ME,,4.13,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/10ML SOSY,186474,CDM,636,RC,J0171,HCPCS,76329331801,NDC,facility,both,0.1,ME,,7.63,5.72,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/10ML SOSY,186474,CDM,636,RC,J0171,HCPCS,409493301,NDC,facility,both,0.1,ME,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
TILDRAKIZUMAB-ASMN 100 MG/ML SOSY,186479,CDM,636,RC,J3245,HCPCS,47335017795,NDC,facility,both,1,ME,,325.58,244.18,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE 5 G PACK,186481,CDM,250,RC,310110501,NDC,,,facility,both,2,UN,,45.18,33.88,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE 5 G PACK,186481,CDM,250,RC,310110530,NDC,,,facility,both,2,UN,,37.08,27.81,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE 5 G PACK,186481,CDM,250,RC,310110501,NDC,,,facility,both,1,UN,,50.65,37.99,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PACK,186482,CDM,250,RC,310111001,NDC,,,facility,both,0.5,UN,,27.5,20.63,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PACK,186482,CDM,250,RC,310111001,NDC,,,facility,both,2,UN,,39.8,29.85,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PACK,186482,CDM,250,RC,310111001,NDC,,,facility,both,1,UN,,45.1,33.82,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PACK,186482,CDM,250,RC,310111030,NDC,,,facility,both,0.5,UN,,26.25,19.69,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE 10 G PACK,186482,CDM,250,RC,310111030,NDC,,,facility,both,1,UN,,42.35,31.76,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 40 MCG/ML SOSY,186493,CDM,636,RC,J2370,HCPCS,69374095510,NDC,facility,both,1,ML,,57.7,43.28,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 40 MCG/ML SOSY,186493,CDM,636,RC,J2371,HCPCS,69374095510,NDC,facility,both,2.5,ML,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 40 MCG/ML SOSY,186493,CDM,636,RC,J2371,HCPCS,69374095510,NDC,facility,both,1,ML,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186495,CDM,250,RC,J2371,HCPCS,69374095710,NDC,facility,both,20,ME,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186495,CDM,636,RC,71449000115,NDC,,,facility,both,20,ME,,34.04,25.53,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186495,CDM,250,RC,J2371,HCPCS,71449000115,NDC,facility,both,20,ME,,36.48,27.36,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,20,ML,,23.71,17.78,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,35,ML,,29.09,21.82,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,70,ML,,26.21,19.66,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,15,ML,,35.72,26.79,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,150,ML,,23.79,17.84,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,25,ML,,31.19,23.39,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,2.5,ML,,45.35,34.01,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,2.5,ML,,40.6,30.45,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,25,ML,,22.05,16.54,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,75,ML,,25.97,19.47,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,2.7,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,1,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,100,ML,,16.62,12.46,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,10,ML,,32.02,24.02,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,80,ML,,25.74,19.3,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,40,ML,,28.44,21.33,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,2,ML,,39,29.25,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,60,ML,,17.96,13.47,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,70092111944,NDC,,,facility,both,5,ML,,44.55,33.41,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,10,ML,,41.25,30.94,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,120,ML,,24.43,18.32,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,15,ML,,26.48,19.86,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,3,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,100,ML,,25.02,18.76,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,30,ML,,29.97,22.47,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,9,ML,,38.8,29.1,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,38,ML,,27.24,20.43,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,5,ML,,48.55,36.41,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,50,ML,,18.58,13.93,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,5,ML,,57.85,43.39,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,50,ML,,27.47,20.6,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,20,ML,,32.95,24.71,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,2,ML,,42.8,32.1,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,30,ML,,20.94,15.71,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,45,ML,,27.93,20.95,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,3,ML,,42.2,31.65,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,69374098255,NDC,,,facility,both,40,ML,,19.49,14.62,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY,186498,CDM,250,RC,71449006811,NDC,,,facility,both,5.5,ML,,30.18,22.63,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML SOSY 5 ML SYRINGE,186498,CDM,250,RC,71449006811,NDC,,,facility,both,5,ML,,57.85,43.39,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,1.25,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,2.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,15,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,1.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,6.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,0.3,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,30,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,3,ML,,1.25,0.94,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,14,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,22,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,2,ML,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,23,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,20,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,13.5,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,1.5,ML,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,24,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,2,ML,,1.23,0.93,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,28,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,7.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,0.75,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,6,ML,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,8.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,1,ML,,56.81,42.61,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,10,ML,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,16,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,12,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,12,ML,,77.4,58.05,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,11,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,9.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,5.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,7,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,0.1,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,1,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,10,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,4,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,17,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,0.4,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,2.5,ML,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,4.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,8,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,0.8,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,3,ML,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,10.5,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,6.75,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,6,ML,,1.21,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,17.5,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,18,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,8,ML,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,13,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,26,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2370,HCPCS,69374095710,NDC,facility,both,4,ML,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,3.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,35,ML,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,5,ML,,1.24,0.93,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,0.5,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 MG/10ML SOSY,186550,CDM,636,RC,J2371,HCPCS,69374095710,NDC,facility,both,9,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG/24HR PTWK,186883,CDM,250,RC,591350804,NDC,,,facility,both,1,UN,,64.8,48.6,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG/24HR PTWK,186884,CDM,250,RC,378087299,NDC,,,facility,both,1,UN,,59.6,44.7,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.3 MG/24HR PTWK,186885,CDM,250,RC,378087399,NDC,,,facility,both,1,UN,,66.15,49.61,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1 G SOLR,186887,CDM,636,RC,J3370,HCPCS,67457034001,NDC,facility,both,500,ME,,20.35,15.26,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1 G SOLR,186887,CDM,636,RC,J3370,HCPCS,63323028420,NDC,facility,both,500,ME,,21.39,16.04,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1 G SOLR 1 EACH VIAL,186887,CDM,636,RC,J3370,HCPCS,16714030910,NDC,facility,both,500,ME,,20.95,15.71,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1 G SOLR 1 EACH VIAL,186887,CDM,636,RC,J3370,HCPCS,67457034001,NDC,facility,both,500,ME,,20.11,15.08,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1 G SOLR 1 EACH VIAL,186887,CDM,636,RC,J3370,HCPCS,63323028420,NDC,facility,both,500,ME,,20.34,15.26,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1 G SOLR 1 EACH VIAL,186887,CDM,636,RC,J3371,HCPCS,67457034001,NDC,facility,both,500,ME,,20.35,15.26,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1 G SOLR 1 EACH VIAL,186887,CDM,636,RC,J3370,HCPCS,409653321,NDC,facility,both,500,ME,,45.1,33.82,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 5 G SOLR 1 EACH VIAL,186888,CDM,636,RC,J3370,HCPCS,72572080301,NDC,facility,both,500,ME,,16.99,12.74,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 5 G SOLR 1 EACH VIAL,186888,CDM,636,RC,J3370,HCPCS,409650901,NDC,facility,both,500,ME,,20.17,15.12,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-AAFI 480 MCG/0.8 ML SOSY,186890,CDM,636,RC,Q5110,HCPCS,69029201,NDC,facility,both,0.8,ML,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,46,ML,,160,120,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,550,ML,,119.41,89.56,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,50,ML,,169.35,127.01,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,2,ML,,38.45,28.84,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,20,ML,,97.75,73.31,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,47,ML,,162.35,121.76,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,10,ML,,73.85,55.39,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,38,ML,,140.75,105.56,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,35,ML,,133.6,100.2,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,15,ML,,85.8,64.35,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,42,ML,,150.35,112.76,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,30,ML,,121.65,91.24,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,25,ML,,109.7,82.28,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,40,ML,,145.5,109.12,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,48,ML,,164.7,123.52,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,45,ML,,157.6,118.2,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPINEPHRINE-CLONIDINE-KETOROLAC 2.46-0.005-0.0008-0.3 MG/ML SOSY,186911,CDM,250,RC,70092143350,NDC,,,facility,both,31,ML,,124.05,93.04,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 2.5 MG TABS,187183,CDM,250,RC,50458057760,NDC,,,facility,both,2,UN,,15.29,11.47,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 2.5 MG TABS,187183,CDM,250,RC,50458057760,NDC,,,facility,both,4,UN,,12.69,9.52,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 2.5 MG TABS,187183,CDM,250,RC,50458057760,NDC,,,facility,both,1,UN,,20.01,15,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 2.5 MG TABS,187183,CDM,250,RC,50458057760,NDC,,,facility,both,6,UN,,12.39,9.29,,,,,,,,,,Gross Charge Type: Pharmacy
CEMIPLIMAB-RWLC 50 MG/ML SOLN 7 ML VIAL,187240,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,both,1,ME,,77.57,58.18,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,3.2,ML,,34.35,25.76,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,12,ML,,30.05,22.54,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,1.2,ML,,44.75,33.56,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,3,ML,,67.5,50.62,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,4,ML,,36.7,27.52,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,3.6,ML,,35.52,26.64,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,2.8,ML,,66.35,49.76,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,2.4,ML,,64,48,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,1.4,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,1.8,ML,,54.6,40.95,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,2,ML,,57.9,43.42,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE LOCK FLUSH 120 MG/3ML SOSY,187286,CDM,250,RC,70092114843,NDC,,,facility,both,1.6,ML,,51.35,38.51,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG TABS,18731,CDM,250,RC,42806033901,NDC,,,facility,both,1.5,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG TABS,18731,CDM,250,RC,555097102,NDC,,,facility,both,3,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG TABS,18731,CDM,250,RC,42806033901,NDC,,,facility,both,2,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG TABS,18731,CDM,250,RC,42806033901,NDC,,,facility,both,1,UN,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG TABS,18731,CDM,250,RC,555097102,NDC,,,facility,both,1,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG TABS,18731,CDM,250,RC,555097102,NDC,,,facility,both,0.5,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG TABS,18736,CDM,250,RC,68462033090,NDC,,,facility,both,2,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG TABS,18736,CDM,250,RC,68462033090,NDC,,,facility,both,4,UN,,1.86,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG TABS,18736,CDM,250,RC,68462033090,NDC,,,facility,both,5,UN,,1.56,1.17,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG TABS,18736,CDM,250,RC,68462033090,NDC,,,facility,both,1,UN,,6.31,4.73,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG TABS,18741,CDM,250,RC,60687059221,NDC,,,facility,both,3,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG TABS,18741,CDM,250,RC,60687059221,NDC,,,facility,both,1.5,UN,,5.42,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG TABS,18741,CDM,250,RC,60687059221,NDC,,,facility,both,1,UN,,9.38,7.03,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG TABS,18741,CDM,250,RC,68462033390,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG TABS,18741,CDM,250,RC,60687059221,NDC,,,facility,both,2.25,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG TABS,18741,CDM,250,RC,60687059221,NDC,,,facility,both,0.5,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG TABS,18741,CDM,250,RC,68462033390,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG TABS,18741,CDM,250,RC,60687059221,NDC,,,facility,both,2,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG TABS,18741,CDM,250,RC,60687059221,NDC,,,facility,both,4,UN,,3.91,2.93,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,904670461,NDC,,,facility,both,1,UN,,7.28,5.46,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,904670461,NDC,,,facility,both,3,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,68462033190,NDC,,,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,57237018190,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,904670461,NDC,,,facility,both,0.5,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,68462033190,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,904670461,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,68462033190,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,904670461,NDC,,,facility,both,1.5,UN,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG TABS,18749,CDM,250,RC,904670461,NDC,,,facility,both,4,UN,,2.48,1.86,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG/ML SOSY,187576,CDM,636,RC,J2357,HCPCS,50242021501,NDC,facility,both,5,ME,,107.36,80.52,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG/ML SOSY,187577,CDM,636,RC,J2357,HCPCS,50242021401,NDC,facility,both,5,ME,,105.39,79.04,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 75 MG/0.5 ML SOSY,187577,CDM,636,RC,J2357,HCPCS,50242021401,NDC,facility,both,5,ME,,105.39,79.04,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 75 MG/0.5ML SOSY,187577,CDM,636,RC,J2357,HCPCS,50242021401,NDC,facility,both,5,ME,,108.49,81.37,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID 500 MG TABS,1877,CDM,250,RC,904052361,NDC,,,facility,both,0.5,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID 500 MG TABS,1877,CDM,250,RC,904052361,NDC,,,facility,both,4,UN,,1.7,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID 500 MG TABS,1877,CDM,250,RC,904052361,NDC,,,facility,both,2,UN,,3.2,2.4,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID 500 MG TABS,1877,CDM,250,RC,904052361,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 500 MG/50ML SOLN 50 ML VIAL,187755,CDM,636,RC,J0640,HCPCS,63323063150,NDC,facility,both,50,ME,,20.32,15.24,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOXIFYLLINE 400 MG TBCR,18777,CDM,250,RC,904544861,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-CBQV 6 MG/0.6ML SOSY,187876,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,both,0.5,ME,,652.45,489.33,,,,,,,,,,Gross Charge Type: Pharmacy
COAG FACT XA INACTIVATED-ZHZO 200 MG SOLR 1 EACH VIAL,188256,CDM,636,RC,J7169,HCPCS,69853010201,NDC,facility,both,10,ME,,639.68,479.76,,,,,,,,,,Gross Charge Type: Pharmacy
DEHYDRATED ALCOHOL SOLN,188715,CDM,250,RC,54288010515,NDC,,,facility,both,20,ML,,1875.82,1406.87,,,,,,,,,,Gross Charge Type: Pharmacy
DEHYDRATED ALCOHOL SOLN,188715,CDM,250,RC,54288010515,NDC,,,facility,both,40,ML,,1875.82,1406.86,,,,,,,,,,Gross Charge Type: Pharmacy
DEHYDRATED ALCOHOL SOLN,188715,CDM,250,RC,54288010502,NDC,,,facility,both,20,ML,,1875.82,1406.87,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG/2ML SOLN,188891,CDM,636,RC,J0780,HCPCS,641613525,NDC,facility,both,10,ME,,59.25,44.44,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG/2ML SOLN,188891,CDM,636,RC,J0780,HCPCS,25021079002,NDC,facility,both,10,ME,,36.56,27.42,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG/2ML SOLN,188891,CDM,636,RC,J0780,HCPCS,23155029442,NDC,facility,both,10,ME,,35.43,26.57,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG/2ML SOLN,188891,CDM,636,RC,J0780,HCPCS,713035125,NDC,facility,both,10,ME,,40.67,30.5,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG/2ML SOLN,188891,CDM,636,RC,J0780,HCPCS,23155049742,NDC,facility,both,10,ME,,54.6,40.95,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 10 MG/2ML SOLN,188891,CDM,636,RC,J0780,HCPCS,67457064099,NDC,facility,both,10,ME,,80.45,60.33,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 117 MG/0.75ML SUSY,188902,CDM,636,RC,J2426,HCPCS,50458056201,NDC,facility,both,1,ME,,24.08,18.06,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE ER 234 MG/1.5ML SUSY,188904,CDM,636,RC,J2426,HCPCS,50458056401,NDC,facility,both,1,ME,,27.27,20.45,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 100 MG/5ML SOSY,188918,CDM,636,RC,J2001,HCPCS,76329339001,NDC,facility,both,1,ME,,5.9,4.43,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 100 MG/5ML SOSY,188918,CDM,636,RC,J2001,HCPCS,409132305,NDC,facility,both,1,ME,,4.86,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 100 MG/5ML SOSY,188918,CDM,636,RC,J2001,HCPCS,409490311,NDC,facility,both,1,ME,,6.01,4.51,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 100 MG/5ML SOSY,188918,CDM,636,RC,J2001,HCPCS,409490334,NDC,facility,both,1,ME,,4.42,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (IV) PF 100 MG/5ML SOSY,188919,CDM,636,RC,J2001,HCPCS,76329339001,NDC,facility,both,1,ME,,5.9,4.43,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (IV) PF 100 MG/5ML SOSY,188919,CDM,636,RC,J2001,HCPCS,409132305,NDC,facility,both,1,ME,,4.86,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A-HEPATITIS B VACCINE 720-20 ELU-MCG/ML SUSY,188921,CDM,636,RC,90636,HCPCS,58160081552,NDC,facility,both,1,ML,,97.5,73.12,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SC SOSY,188922,CDM,55513071001,NDC,,,,,facility,both,1,ML,,48.98,36.73,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SOSY,188922,CDM,636,RC,J0897,HCPCS,55513071001,NDC,facility,both,1,ME,,60.88,45.66,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 2 UNITS/ML IN NS 2 UNITS/ML SOLN,188932,CDM,636,RC,J1644,HCPCS,338042418,NDC,facility,both,1000,UN,,26.1,19.58,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 2 UNITS/ML IN NS 2 UNITS/ML SOLN,188932,CDM,636,RC,J1644,HCPCS,409762003,NDC,facility,both,1000,UN,,49.86,37.39,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 2 UNITS/ML IN NS 2 UNITS/ML SOLN,188932,CDM,636,RC,J1644,HCPCS,264987210,NDC,facility,both,1000,UN,,55.8,41.85,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML IN D5W 50 UNITS/ML SOLN,188935,CDM,636,RC,J1644,HCPCS,63323052277,NDC,facility,both,1000,UN,,3.02,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML IN D5W 50 UNITS/ML SOLN,188935,CDM,636,RC,J1644,HCPCS,409315020,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML IN D5W 50 UNITS/ML SOLN,188935,CDM,636,RC,J1644,HCPCS,264957710,NDC,facility,both,1000,UN,,3.64,2.73,,,,,,,,,,Gross Charge Type: Pharmacy
ATEZOLIZUMAB 840 MG/14ML SOLN 14 ML VIAL,188985,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,both,10,ME,,230.7,173.03,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.36 G CAPS,188991,CDM,250,RC,37000040511,NDC,,,facility,both,6,UN,,1.48,1.11,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.36 G CAPS,188991,CDM,250,RC,37000040511,NDC,,,facility,both,2,UN,,3.62,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.36 G CAPS,188991,CDM,250,RC,37000040511,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.36 G CAPS,188991,CDM,250,RC,37000040511,NDC,,,facility,both,1.444444444,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B SOLR 1 EACH VIAL,189080,CDM,636,RC,J0285,HCPCS,39822105505,NDC,facility,both,50,ME,,425.45,319.09,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,7.5,ML,,50.35,37.76,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,100,ML,,83.14,62.35,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,10,ML,,51.35,38.51,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,5.5,ML,,49.6,37.2,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,7,ML,,50.15,37.61,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,8,ML,,50.55,37.91,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,17,ML,,54.1,40.58,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,12.5,ML,,52.35,39.26,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,15.5,ML,,53.5,40.12,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,4.5,ML,,49.15,36.86,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,3,ML,,48.55,36.41,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,12,ML,,52.15,39.11,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,6,ML,,49.75,37.31,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,11,ML,,51.75,38.81,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,14,ML,,52.9,39.68,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,5,ML,,49.35,37.01,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,11.5,ML,,51.95,38.96,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,9,ML,,50.95,38.21,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,16,ML,,53.7,40.28,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,15,ML,,53.3,39.98,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,14.5,ML,,53.1,39.82,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,16.5,ML,,53.9,40.42,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,4,ML,,48.95,36.71,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,3.5,ML,,48.75,36.56,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,13,ML,,52.55,39.41,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,8.5,ML,,50.75,38.06,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,6.5,ML,,49.95,37.46,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION **FISH OIL-BASED** (SMOFLIPID) 20 % EMUL,189087,CDM,250,RC,63323082000,NDC,,,facility,both,10.5,ML,,51.55,38.66,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-HYALURONIDASE-OYSK 600-10000 MG-UNIT/5 ML SOLN,189336,CDM,636,RC,J9356,HCPCS,50242007701,NDC,facility,both,10,ME,,225.36,169.02,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 105 MG/1.17ML SC SOSY,189397,CDM,55513088002,NDC,,,,,facility,both,1,ML,,22.56,16.92,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 105 MG/1.17ML SOSY,189397,CDM,636,RC,J3111,HCPCS,55513088002,NDC,facility,both,1,ME,,26.45,19.84,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,20555003300,NDC,,,facility,both,3,UN,,2.25,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,20555003300,NDC,,,facility,both,10,UN,,0.84,0.63,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,20555003300,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,20555003300,NDC,,,facility,both,4,UN,,1.75,1.31,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,20555003300,NDC,,,facility,both,2.5,UN,,2.22,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,20555003300,NDC,,,facility,both,5,UN,,1.45,1.09,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,20555003300,NDC,,,facility,both,6,UN,,1.25,0.94,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,20555003300,NDC,,,facility,both,2,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,48433010401,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 25 MCG (1000 UNITS) TABS,189444,CDM,250,RC,20555003300,NDC,,,facility,both,8,UN,,0.99,0.75,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML SOLN 1 ML VIAL,189589,CDM,636,RC,J3010,HCPCS,63323080611,NDC,facility,both,0.1,ME,,18.57,13.92,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,2,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,1.25,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,4.4,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,both,3.125,ML,,23.18,17.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,5,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J2248,HCPCS,63323088510,NDC,facility,both,3,ML,,231.75,173.81,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,3.75,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,3,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J2248,HCPCS,63323088510,NDC,facility,both,3.75,ML,,231.75,173.81,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,both,3.75,ML,,23.18,17.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,3.5,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,both,1.5,ML,,23.18,17.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,2.5,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,4,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,1.5,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J2248,HCPCS,63323088510,NDC,facility,both,5,ML,,231.75,173.81,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,both,3.5,ML,,23.18,17.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,1,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,10,ML,,42.24,31.68,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,both,4,ML,,23.18,17.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,6.25,ML,,42.24,31.68,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,7,ML,,42.24,31.68,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,both,2.5,ML,,23.18,17.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,250,RC,MHS1ML,HCPCS,63323088510,NDC,facility,both,0.9375,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,both,1,ML,,23.18,17.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG/5ML SOLN,189605,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,both,5,ML,,23.18,17.38,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.65 % SOLN,18965,CDM,250,RC,MHS1ML,HCPCS,56184012011,NDC,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.65 % SOLN,18965,CDM,250,RC,MHS1ML,HCPCS,904386575,NDC,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.65 % SOLN 44 ML BOTTLE,18965,CDM,250,RC,MHS1ML,HCPCS,904386575,NDC,facility,both,1,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.65 % SOLN 45 ML SPRAY BOTTLE,18965,CDM,250,RC,MHS1ML,HCPCS,45802035758,NDC,facility,both,1,ML,,0.18,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMIN A & D OINT 113 G TUBE,189681,CDM,250,RC,71399012204,NDC,,,facility,both,113,GR,,42,31.5,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 80 MG/ML SUSP,189931,CDM,636,RC,J3301,HCPCS,3031505,NDC,facility,both,10,ME,,9.79,7.34,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 80 MG/ML IJ SUSP,189931,CDM,3031505,NDC,,,,,facility,both,10,ML,,9.49,7.11,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML SOLR 1 EACH VIAL,189971,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,both,1,ME,,312.73,234.55,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-ANNS 420 MG SOLR 1 EACH VIAL,190265,CDM,636,RC,Q5117,HCPCS,55513013201,NDC,facility,both,10,ME,,253.12,189.84,,,,,,,,,,Gross Charge Type: Pharmacy
SELENIUM 60 MCG/ML SOLN 10 ML VIAL,190300,CDM,250,RC,517656005,NDC,,,facility,both,1,ML,,86.4,64.8,,,,,,,,,,Gross Charge Type: Pharmacy
SELENIUM 60 MCG/ML SOLN 10 ML VIAL,190300,CDM,250,RC,517656005,NDC,,,facility,both,0.67,ML,,73.7,55.28,,,,,,,,,,Gross Charge Type: Pharmacy
DAROLUTAMIDE 300 MG TABS,190412,CDM,250,RC,50419039501,NDC,,,facility,both,2,UN,,530.02,397.52,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,23.36666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,10.6,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,10.46666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,38.26666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.16666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,12.78333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.033333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,13.5,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.1,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.06666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,21.05,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2.4,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.13333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,21.43333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.933333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,24.9,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,0.866666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.86666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,18.56666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.166666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.916666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.8,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.6,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,17.33333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,12.53333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.333333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.466666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.2,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.566666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.45,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,8.4,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2.883333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,3,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2.933333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,8.566666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2.966666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.8,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,20.76666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,15.83333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,17.6,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,18.45,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,8.6,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,16.08333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,15.8,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.8,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.85,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,23.46666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,6.983333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.166666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.9,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.35,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.433333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,10.3,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,6.033333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,52.03333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,6.233333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.666666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,3.3625,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,23.8,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.816666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.033333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,1.333333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,6.8,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.2,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2.366666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.266666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2.466666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.75,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,35.88333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.4,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.5,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,6.483333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,16.4,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.31666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,17.86666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.25,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,24.43333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.41666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,25.6,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,50.75,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,12.66666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.35,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,13.01666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,85.93333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,12.2,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.833333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,61.23333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.066666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,1.5,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,15,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,17.13333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,6.5,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,18.13333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.33333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,19.05,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,19.41666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,3.333333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,61.83333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.533333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.116666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.6,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.583333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,22.63333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,17.16666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,0.154166667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,23.53333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2.920833333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,32.76666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.716666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,6.466666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.7,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,17.93333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,8.35,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.383333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,1.733333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.85,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,12.36666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,15.85,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,8,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,23.65,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,13.33333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,6.4,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,13.3,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.133333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,24.23333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,17,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.516666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,17.68333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,6.383333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2.866666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,15.26666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.533333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,21.16666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,21.1,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,13.25,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,100,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,10,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4.566666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,3.416666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,33.86666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,25.06666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.433333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,8.033333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,20,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,10.33333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,7.133333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.6,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.1,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,12.15,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,38.53333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,8.933333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.083333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.83333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,33.3,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,16,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,34.55,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.9,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.89166667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,32.23333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,8.633333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,1.1,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.36666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,8.183333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,2.266666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,18.41666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,11.65,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,19.85,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,5.666666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.05,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.53333333,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,4,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,20.45,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,14.96666667,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN,190603,CDM,250,RC,338012612,NDC,,,facility,both,9.8,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS IN NS 100 ML 1 UNIT/ML/100ML-% SOLN 100 ML FLEX CONT,190603,CDM,250,RC,338012612,NDC,,,facility,both,100,ML,,93.25,69.94,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE CAPS,19065,CDM,250,RC,10858008107,NDC,,,facility,both,1,UN,,91.35,68.51,,,,,,,,,,Gross Charge Type: Pharmacy
MEASLES-MUMPS-RUBELLA VACCINE SOLR,190854,CDM,636,RC,90707,HCPCS,6468100,NDC,facility,both,0.5,ML,,30.01,22.51,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488820,NDC,,,facility,both,50,ML,,18.18,13.64,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488820,NDC,,,facility,both,80,ML,,15.99,11.99,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488810,NDC,,,facility,both,5,ML,,10.37,7.77,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,63323018620,NDC,,,facility,both,15,ML,,33.2,24.9,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488810,NDC,,,facility,both,30,ML,,12.33,9.25,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,63323018620,NDC,,,facility,both,5,ML,,33.2,24.9,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488810,NDC,,,facility,both,10,ML,,12.08,9.06,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488820,NDC,,,facility,both,6,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488820,NDC,,,facility,both,20,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,63323018610,NDC,,,facility,both,5,ML,,29.25,21.94,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488810,NDC,,,facility,both,20,ML,,16.5,12.38,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488810,NDC,,,facility,both,15,ML,,16.5,12.38,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488810,NDC,,,facility,both,40,ML,,10.25,7.69,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488810,NDC,,,facility,both,4,ML,,17.82,13.36,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN,190882,CDM,250,RC,409488820,NDC,,,facility,both,10,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,63323018610,NDC,,,facility,both,10,ML,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,409488810,NDC,,,facility,both,0.9,ML,,29,21.75,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,409488810,NDC,,,facility,both,12.5,ML,,16.5,12.38,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,409488810,NDC,,,facility,both,6,ML,,29,21.75,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,409488810,NDC,,,facility,both,2,ML,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,409488810,NDC,,,facility,both,20,ML,,16.5,12.38,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,409488810,NDC,,,facility,both,30,ML,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,63323018610,NDC,,,facility,both,0.9,ML,,29.25,21.94,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,409488810,NDC,,,facility,both,10,ML,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,409488810,NDC,,,facility,both,5,ML,,16.5,12.38,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,409488810,NDC,,,facility,both,8,ML,,29,21.75,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,63323018610,NDC,,,facility,both,4.5,ML,,29.25,21.94,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,63323018610,NDC,,,facility,both,4.4,ML,,29.25,21.94,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 10 ML VIAL,190882,CDM,250,RC,63323018610,NDC,,,facility,both,30,ML,,12.57,9.42,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,0.73,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,25,ML,,22.35,16.76,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,33,ML,,22.35,16.76,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,4.4,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,16,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,20,ML,,32.24,24.18,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,13.7,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,2.2,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,22,ML,,22.35,16.76,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,4.52,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,34.95,ML,,22.35,16.76,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,13.2,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,63323018620,NDC,,,facility,both,13.7,ML,,33.2,24.9,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,10,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,1,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,40,ML,,9.85,7.39,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,6.6,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,63323018620,NDC,,,facility,both,12,ML,,33.2,24.9,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,12.5,ML,,34.85,26.14,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,63323018620,NDC,,,facility,both,20,ML,,25.85,19.39,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 20 ML VIAL,190882,CDM,250,RC,409488820,NDC,,,facility,both,30,ML,,22.35,16.76,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 50 ML VIAL,190882,CDM,250,RC,409488806,NDC,,,facility,both,38.5,ML,,38.05,28.54,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 50 ML VIAL,190882,CDM,250,RC,409488806,NDC,,,facility,both,46.2,ML,,40.65,30.49,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 50 ML VIAL,190882,CDM,250,RC,409488806,NDC,,,facility,both,4.52,ML,,26.55,19.91,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 50 ML VIAL,190882,CDM,250,RC,409488806,NDC,,,facility,both,110,ML,,20.75,15.56,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE PF (NS) 0.9 % NACL 0.9 % SOLN 50 ML VIAL,190882,CDM,250,RC,409488806,NDC,,,facility,both,28.6,ML,,34.7,26.02,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN-CODEINE 300-30 MG TABS,191,CDM,250,RC,406048462,NDC,,,facility,both,2,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN-CODEINE 300-30 MG TABS,191,CDM,250,RC,406048462,NDC,,,facility,both,0.5,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN-CODEINE 300-30 MG TABS,191,CDM,250,RC,406048462,NDC,,,facility,both,1,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,76329301205,NDC,,,facility,both,1,ML,,44.9,33.68,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,FAMRXNC,HCPCS,76329301305,NDC,facility,both,1,ML,,4.74,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,25021067376,NDC,,,facility,both,1,ML,,43.35,32.51,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,76329301105,NDC,,,facility,both,2,ML,,44.9,33.68,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,76329301105,NDC,,,facility,both,12,ML,,20.02,15.01,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,25021067376,NDC,,,facility,both,2,ML,,43.35,32.51,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,FAMRXNC,HCPCS,25021067376,NDC,facility,both,2,ML,,2.87,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,76329301205,NDC,,,facility,both,5,ML,,44.9,33.68,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,FAMRXNC,HCPCS,76329301105,NDC,facility,both,1,ML,,1.67,1.25,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,FAMRXNC,HCPCS,76329301205,NDC,facility,both,1,ML,,2.19,1.64,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,FAMRXNC,HCPCS,76329301205,NDC,facility,both,2,ML,,1.67,1.25,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,25021067376,NDC,,,facility,both,6,ML,,43.35,32.51,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,25021067376,NDC,,,facility,both,5,ML,,43.35,32.51,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,76329301105,NDC,,,facility,both,6,ML,,26.32,19.74,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,J3490,HCPCS,76329301105,NDC,facility,both,1,ML,,8.98,6.74,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,J3490,HCPCS,76329301205,NDC,facility,both,1,ML,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,76329301105,NDC,,,facility,both,1,ML,,44.9,33.68,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,FAMRXNC,HCPCS,25021067377,NDC,facility,both,1,ML,,3.87,2.9,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,FAMRXNC,HCPCS,76329301105,NDC,facility,both,30,ML,,1.67,1.25,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,76329301205,NDC,,,facility,both,2,ML,,44.9,33.68,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,FAMRXNC,HCPCS,25021067376,NDC,facility,both,1,ML,,5.7,4.28,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % PRSY,191074,CDM,250,RC,76329301105,NDC,,,facility,both,5,ML,,44.9,33.68,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 10 MCG/ML (400 UNITS/ML) LIQD,191150,CDM,250,RC,71399740105,NDC,,,facility,both,12.5,ML,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 10 MCG/ML (400 UNITS/ML) LIQD,191150,CDM,250,RC,71399740105,NDC,,,facility,both,1,ML,,5.15,3.86,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 10 MCG/ML (400 UNITS/ML) LIQD,191150,CDM,250,RC,MHS1ML,HCPCS,54838000650,NDC,facility,both,1,ML,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 10 MCG/ML (400 UNITS/ML) LIQD,191150,CDM,250,RC,71399740105,NDC,,,facility,both,0.5,ML,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-DKST 420 MG SOLR 1 EACH VIAL,191462,CDM,636,RC,Q5114,HCPCS,67457084744,NDC,facility,both,10,ME,,134.97,101.23,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-DKST 420 MG SOLR 1 EACH VIAL,191462,CDM,636,RC,Q5114,HCPCS,67457084550,NDC,facility,both,10,ME,,133.37,100.03,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-DKST 420 MG SOLR 1 EACH VIAL,191462,CDM,636,RC,Q5114,HCPCS,83257000412,NDC,facility,both,10,ME,,172.8,129.6,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-DKST 420 MG SOLR 1 EACH VIAL,191462,CDM,636,RC,Q5114,HCPCS,83257000311,NDC,facility,both,10,ME,,170.94,128.2,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-ABBS 10 MG/ML SOLN 10 ML VIAL,191728,CDM,636,RC,Q5115,HCPCS,63459010310,NDC,facility,both,10,ME,,166.34,124.75,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-ABBS 10 MG/ML SOLN 50 ML VIAL,191729,CDM,636,RC,Q5115,HCPCS,63459010450,NDC,facility,both,10,ME,,163.53,122.65,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.72,UN,,235.22,176.42,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.76,UN,,223.46,167.6,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.632,UN,,265.46,199.1,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.8,UN,,235.22,176.42,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.496,UN,,243.07,182.3,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,2,UN,,235.22,176.42,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.2,UN,,373.12,279.84,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.368,UN,,250.86,188.14,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.88,UN,,235.22,176.42,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.44,UN,,262.51,196.88,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,1,UN,,226.17,169.63,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.56,UN,,235.22,176.42,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.84,UN,,246.98,185.24,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.6,UN,,252.02,189.02,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.24,UN,,310.9,233.18,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.12,UN,,454.2,340.65,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.52,UN,,247.12,185.34,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.64,UN,,235.22,176.42,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.48,UN,,238.5,178.87,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,1.504,UN,,232.74,174.56,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,1.16,UN,,227.38,170.54,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.4,UN,,262.02,196.52,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,0.36,UN,,308.71,231.53,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG/ML SOLR,191732,CDM,636,RC,J2796,HCPCS,55513022301,NDC,facility,both,1.28,UN,,235.22,176.42,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 50 MG/ML SOLR 1 EACH VIAL,191766,CDM,636,RC,J0896,HCPCS,59572071101,NDC,facility,both,0.25,ME,,94.09,70.56,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 50 MG/ML SOLR 1 EACH VIAL,191767,CDM,636,RC,J0896,HCPCS,59572077501,NDC,facility,both,0.25,ME,,94.39,70.79,,,,,,,,,,Gross Charge Type: Pharmacy
CRIZANLIZUMAB-TMCA 10 MG/ML SOLN 10 ML VIAL,191811,CDM,636,RC,J0791,HCPCS,78088361,NDC,facility,both,5,ME,,302.43,226.82,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN-CODEINE 300-60 MG TABS,192,CDM,250,RC,406048501,NDC,,,facility,both,1,UN,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN-CODEINE 300-60 MG TABS,192,CDM,250,RC,406048501,NDC,,,facility,both,2,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 10 MG/ML SOLR 1 EACH VIAL,192046,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,both,0.25,ME,,90.09,67.57,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 10 MG/ML SOLR 1 EACH VIAL,192047,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,both,0.25,ME,,95.29,71.47,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTEC-NXKI 20 MG/ML SOLR 1 EACH VIAL,192076,CDM,636,RC,J9358,HCPCS,65597040601,NDC,facility,both,1,ME,,73.41,55.06,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML SOLN 4 ML VIAL,192168,CDM,636,RC,Q5118,HCPCS,69031501,NDC,facility,both,10,ME,,170.48,127.86,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML SOLN 16 ML VIAL,192169,CDM,636,RC,Q5118,HCPCS,69034201,NDC,facility,both,10,ME,,152.49,114.37,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML SOLN 4 ML VIAL,192169,CDM,636,RC,Q5118,HCPCS,69031501,NDC,facility,both,10,ME,,165.43,124.07,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML SOLN 10 ML VIAL,192171,CDM,636,RC,Q5119,HCPCS,69023801,NDC,facility,both,10,ME,,160.06,120.04,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML SOLN 50 ML VIAL,192172,CDM,636,RC,Q5119,HCPCS,69024901,NDC,facility,both,10,ME,,158.61,118.96,,,,,,,,,,Gross Charge Type: Pharmacy
LUMATEPERONE TOSYLATE 42 MG CAPS,192184,CDM,250,RC,72060014240,NDC,,,facility,both,1,UN,,92.45,69.34,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,66553000201,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,1,UN,,6.39,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,8.024691358,UN,,0.98,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,66553000201,NDC,,,facility,both,3,UN,,2.43,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043401,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,FAMRXNC,HCPCS,904404073,NDC,facility,both,3,UN,,2.13,1.6,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,66553000201,NDC,,,facility,both,3.5,UN,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043401,NDC,,,facility,both,4,UN,,1.81,1.36,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,0.25,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,4,UN,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043401,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,3.012345679,UN,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,66553000201,NDC,,,facility,both,1,UN,,6.44,4.83,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,3,UN,,2.34,1.75,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,4,UN,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043401,NDC,,,facility,both,0.25,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,66553000201,NDC,,,facility,both,0.25,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,8,UN,,1.1,0.82,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,66553000201,NDC,,,facility,both,4,UN,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,3.5,UN,,1.86,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,66553000201,NDC,,,facility,both,2,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043401,NDC,,,facility,both,3,UN,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,3.469135803,UN,,1.86,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,2,UN,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,7.0247,UN,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,3.5,UN,,1.82,1.37,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,0.25,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,7,UN,,1.21,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,3,UN,,2.26,1.7,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679480,NDC,,,facility,both,4,UN,,1.54,1.15,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679480,NDC,,,facility,both,2,UN,,1.55,1.16,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043401,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043402,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904404073,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679430,NDC,,,facility,both,2.4877,UN,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679480,NDC,,,facility,both,3,UN,,2.05,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,904679480,NDC,,,facility,both,1,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG CHEW,1922,CDM,250,RC,63739043401,NDC,,,facility,both,4.012345679,UN,,1.45,1.09,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 50 MG/ML SOLR 1 EACH VIAL,192318,CDM,636,RC,J3241,HCPCS,75987013015,NDC,facility,both,10,ME,,773.51,580.13,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 325 MG TABS,1925,CDM,250,RC,536105429,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 325 MG TABS,1925,CDM,250,RC,57896090101,NDC,,,facility,both,0.249230769,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 325 MG TABS,1925,CDM,250,RC,57896090101,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 325 MG TABS,1925,CDM,250,RC,57896090101,NDC,,,facility,both,2,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 325 MG TABS,1925,CDM,250,RC,57896090101,NDC,,,facility,both,0.5,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 325 MG TABS,1925,CDM,250,RC,57896090101,NDC,,,facility,both,0.747692308,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 21 MG/ML SOLR 1 EACH VIAL,192722,CDM,636,RC,Q5116,HCPCS,69030501,NDC,facility,both,10,ME,,161.26,120.94,,,,,,,,,,Gross Charge Type: Pharmacy
CEFIDEROCOL SULFATE TOSYLATE 1 G SOLR 1 EACH VIAL,192727,CDM,250,RC,59630026610,NDC,,,facility,both,2,UN,,573.65,430.24,,,,,,,,,,Gross Charge Type: Pharmacy
CEFIDEROCOL SULFATE TOSYLATE 1 G SOLR 1 EACH VIAL,192727,CDM,250,RC,59630026601,NDC,,,facility,both,2,UN,,556.7,417.52,,,,,,,,,,Gross Charge Type: Pharmacy
EPTINEZUMAB-JJMR 100 MG/ML SOLN 1 ML VIAL,192912,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,both,1,ME,,41.75,31.31,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,3.334,ML,,53.3,39.98,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,16.67,ML,,37.98,28.48,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,1.67,ML,,50.35,37.76,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,5,ML,,56.25,42.19,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,1.3,ML,,49.7,37.28,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,0.13,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,8,ML,,61.35,46.01,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,0.1,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,2,ML,,50.95,38.21,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,20,ML,,40.75,30.56,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,6.667,ML,,59.1,44.32,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,3.3,ML,,53.25,39.94,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,8.3,ML,,61.85,46.39,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,65219005429,NDC,,,facility,both,3.334,ML,,64.35,48.26,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,10,ML,,64.7,48.52,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,11.67,ML,,67.5,50.62,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,8.33,ML,,61.9,46.42,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,13.334,ML,,70.3,52.72,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,0.07,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,4.546,ML,,55.45,41.59,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,6,ML,,58,43.5,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,6.7,ML,,59.15,44.36,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,65219005429,NDC,,,facility,both,6.667,ML,,80.8,60.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,13.33,ML,,70.3,52.72,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,2.67,ML,,52.1,39.08,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,2.7,ML,,52.2,39.15,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,0.27,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,6.67,ML,,59.1,44.32,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,3.33,ML,,53.3,39.98,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,1.7,ML,,50.4,37.8,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,65219005429,NDC,,,facility,both,10,ML,,97.2,72.9,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 3 MMOLE/ML SOLN 15 ML VIAL,192927,CDM,250,RC,409729501,NDC,,,facility,both,4,ML,,54.45,40.84,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 325 MG TBEC,1931,CDM,250,RC,536123201,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-PKRB 420 MG SOLR 1 EACH VIAL,193155,CDM,636,RC,Q5113,HCPCS,63459030547,NDC,facility,both,10,ME,,160.29,120.22,,,,,,,,,,Gross Charge Type: Pharmacy
AFAMELANOTIDE ACETATE 16 MG IMPL,193159,CDM,636,RC,J7352,HCPCS,73372011601,NDC,facility,both,1,ME,,6684.18,5013.13,,,,,,,,,,Gross Charge Type: Pharmacy
TERIPARATIDE 600 MCG/2.4ML SOPN,193163,CDM,636,RC,J3110,HCPCS,2840001,NDC,facility,both,0.08,ML,,196.92,147.69,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX ACETATE 120 MG/VIAL SOLR,193165,CDM,636,RC,J9155,HCPCS,55566840301,NDC,facility,both,1,ME,,20.4,15.3,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN 900 UNIT/3ML SOLN,193218,CDM,636,RC,90375,HCPCS,13533031803,NDC,facility,both,150,UN,,572.2,429.15,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN 900 UNIT/3ML SOLN,193218,CDM,636,RC,90375,HCPCS,13533031830,NDC,facility,both,150,UN,,566.64,424.98,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG TBEC,1934,CDM,250,RC,63739021202,NDC,,,facility,both,4,UN,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG TBEC,1934,CDM,250,RC,49483048112,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG TBEC,1934,CDM,250,RC,63739021202,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG TBEC,1934,CDM,250,RC,904675180,NDC,,,facility,both,1,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG TBEC,1934,CDM,250,RC,63739021202,NDC,,,facility,both,3,UN,,2.28,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG TBEC,1934,CDM,250,RC,57896098101,NDC,,,facility,both,4,UN,,1.59,1.19,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG TBEC,1934,CDM,250,RC,57896098101,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG TBEC,1934,CDM,250,RC,63739021202,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG TBEC,1934,CDM,250,RC,57896098101,NDC,,,facility,both,2,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE-PRAMOXINE 1-1 % FOAM 10 G CAN,193408,CDM,250,RC,MHS1GM,HCPCS,37682210,NDC,facility,both,1,GM,,25.4,19.05,,,,,,,,,,Gross Charge Type: Pharmacy
TERIPARATIDE (RECOMBINANT) 620 MCG/2.48ML SOPN,193446,CDM,637,RC,2840001,NDC,,,facility,both,0.08,ML,,393.85,295.39,,,,,,,,,,Gross Charge Type: Pharmacy
REMDESIVIR 100 MG SOLR 1 EACH VIAL,193682,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,both,1,ME,,14.18,10.63,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN/ZINC STRESS TABS,193697,CDM,250,RC,80681011200,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-DTTB 21 MG/ML SOLR 1 EACH VIAL,193746,CDM,636,RC,Q5112,HCPCS,78206014801,NDC,facility,both,10,ME,,218.79,164.1,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG SOLR 1 EACH VIAL,193787,CDM,636,RC,J9317,HCPCS,55135013201,NDC,facility,both,2.5,ME,,88.76,66.57,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-ARRX 100 MG/10ML SOLN 10 ML VIAL,193949,CDM,636,RC,Q5123,HCPCS,55513022401,NDC,facility,both,10,ME,,170.15,127.61,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-ARRX 10 MG/ML SOLN 50 ML VIAL,193951,CDM,636,RC,Q5123,HCPCS,55513032601,NDC,facility,both,10,ME,,168.49,126.37,,,,,,,,,,Gross Charge Type: Pharmacy
CALAMINE-ZINC OXIDE 8-8 % LOTN 177 ML BOTTLE,193961,CDM,250,RC,395041396,NDC,,,facility,both,177,ML,,42.25,31.69,,,,,,,,,,Gross Charge Type: Pharmacy
CALAMINE-ZINC OXIDE 8-8 % LOTN 177 ML BOTTLE,193961,CDM,250,RC,904253321,NDC,,,facility,both,177,ML,,38.8,29.1,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG SOLR 1 EACH VIAL,194008,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,both,10,ME,,117.81,88.36,,,,,,,,,,Gross Charge Type: Pharmacy
DARATUMUMAB-HYALURONIDASE-FIHJ 1800-30000 MG-UT/15ML SOLN,194034,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,both,10,ME,,140.75,105.56,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 80 (2 X 40) MG SOLR,194078,CDM,636,RC,J9281,HCPCS,72493010303,NDC,facility,both,1,ME,,977.45,733.09,,,,,,,,,,Gross Charge Type: Pharmacy
REMDESIVIR EUA 5 MG/ML SOLN 1 EACH VIAL,194082,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,both,1,ME,,14.22,10.67,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 0.133 MG/ML SOLN,194084,CDM,250,RC,68094012962,NDC,,,facility,both,15,ML,,120.3,90.22,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 0.133 MG/ML SOLN,194084,CDM,250,RC,68094012962,NDC,,,facility,both,30,ML,,111.15,83.36,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 0.133 MG/ML SOLN 120 ML BOTTLE,194084,CDM,250,RC,70677005401,NDC,,,facility,both,30,ML,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 0.133 MG/ML SOLN 120 ML BOTTLE,194084,CDM,250,RC,70677005401,NDC,,,facility,both,15,ML,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 0.133 MG/ML SOLN 120 ML BOTTLE,194084,CDM,250,RC,70677005401,NDC,,,facility,both,7.5,ML,,5.5,4.12,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE HCL 1 MG/7.5ML SOLN,194084,CDM,250,RC,68094012962,NDC,,,facility,both,15,ML,,120.3,90.22,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE HCL 1 MG/7.5ML SOLN,194084,CDM,250,RC,68094012962,NDC,,,facility,both,30,ML,,111.15,83.36,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 300 MG SUPP,1942,CDM,250,RC,574703412,NDC,,,facility,both,1.08,UN,,11.45,8.59,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 300 MG SUPP,1942,CDM,250,RC,574703412,NDC,,,facility,both,0.27,UN,,20.75,15.56,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 300 MG SUPP,1942,CDM,250,RC,574703412,NDC,,,facility,both,1,UN,,22.7,17.02,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 300 MG SUPP,1942,CDM,250,RC,574703412,NDC,,,facility,both,0.81,UN,,22.2,16.65,,,,,,,,,,Gross Charge Type: Pharmacy
LURBINECTEDIN 0.5 MG/ML SOLR 1 EACH VIAL,194443,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,both,0.1,ME,,539.85,404.89,,,,,,,,,,Gross Charge Type: Pharmacy
LETROZOLE 2.5 MG TABS,19455,CDM,250,RC,50268047615,NDC,,,facility,both,1,UN,,42.9,32.18,,,,,,,,,,Gross Charge Type: Pharmacy
LETROZOLE 2.5 MG TABS,19455,CDM,250,RC,51991075933,NDC,,,facility,both,1,UN,,38.15,28.61,,,,,,,,,,Gross Charge Type: Pharmacy
PERTUZUMAB-TRASTUZUMAB-HYALURONIDASE-ZZXF 60-60-2000 MG-MG-UNITS/ML SOLN,194694,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,both,10,ME,,194.85,146.14,,,,,,,,,,Gross Charge Type: Pharmacy
PERTUZUMAB-TRASTUZUMAB-HYALURONIDASE-ZZXF 80-40-2000 MG-MG-UNIT/ML SOLN,194695,CDM,636,RC,J9316,HCPCS,50242024501,NDC,facility,both,10,ME,,192.05,144.03,,,,,,,,,,Gross Charge Type: Pharmacy
TRALEMENT 300-55-60-3000 MCG/ML SOLN 1 ML VIAL,194965,CDM,250,RC,517930525,NDC,,,facility,both,1,ML,,83.64,62.73,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % CREA 25 G TUBE,19497,CDM,250,RC,MHS1GM,HCPCS,43598021025,NDC,facility,both,1,GM,,1.71,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % CREA 25 G TUBE,19497,CDM,250,RC,MHS1GM,HCPCS,67877012425,NDC,facility,both,1,GM,,1.9,1.43,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % CREA 25 G TUBE,19497,CDM,250,RC,MHS1GM,HCPCS,61570013125,NDC,facility,both,1,GM,,1.84,1.38,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % CREA 400 G JAR,19497,CDM,250,RC,MHS1GM,HCPCS,43598021040,NDC,facility,both,1,GM,,0.23,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % CREA 400 G JAR,19497,CDM,250,RC,MHS1GM,HCPCS,67877012440,NDC,facility,both,1,GM,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % CREA 50 G JAR,19497,CDM,250,RC,MHS1GM,HCPCS,43598021055,NDC,facility,both,1,GM,,0.94,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % CREA 85 G TUBE,19497,CDM,250,RC,MHS1GM,HCPCS,43598021085,NDC,facility,both,1,GM,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % EX CREA,19497,CDM,43598021025,NDC,,,,,facility,both,1,GM,,1.71,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % EX CREA,19497,CDM,61570013125,NDC,,,,,facility,both,1,GM,,2.31,1.73,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % EX CREA,19497,CDM,61570013120,NDC,,,,,facility,both,1,GM,,2.55,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 80 MG CHEW,19502,CDM,250,RC,63739022510,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 80 MG CHEW,19502,CDM,250,RC,49348014707,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 80 MG CHEW,19502,CDM,250,RC,77333081210,NDC,,,facility,both,3,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 80 MG CHEW,19502,CDM,250,RC,77333081210,NDC,,,facility,both,1.5,UN,,3.82,2.87,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 80 MG CHEW,19502,CDM,250,RC,63739022510,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 80 MG CHEW,19502,CDM,250,RC,77333081210,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 80 MG CHEW,19502,CDM,250,RC,77333081210,NDC,,,facility,both,2,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 80 MG CHEW,19502,CDM,250,RC,77333081210,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 80 MG CHEW,19502,CDM,250,RC,57896079101,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
METHACHOLINE KIT,195023,CDM,250,RC,J7674,HCPCS,69374054206,NDC,facility,both,1,ME,,38.17,28.62,,,,,,,,,,Gross Charge Type: Pharmacy
METHACHOLINE KIT,195023,CDM,250,RC,J7674,HCPCS,64281011006,NDC,facility,both,1,ME,,38.17,28.62,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6ML SUSP,19503,CDM,250,RC,MHS1ML,HCPCS,536130375,NDC,facility,both,1,ML,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,19503,CDM,250,RC,MHS1ML,HCPCS,536130375,NDC,facility,both,1,ML,,0.3,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6ML SUSP 30 ML BOTTLE,19503,CDM,250,RC,MHS1ML,HCPCS,904589430,NDC,facility,both,1,ML,,0.31,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 30 MG SOLR 1 EACH VIAL,195379,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,both,1,ME,,314.69,236.02,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.4 MG/10ML SOLN,195386,CDM,636,RC,69374030510,NDC,,,facility,both,10,ML,,54.65,40.99,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.4 MG/10ML SOLN,195386,CDM,636,RC,69374030510,NDC,,,facility,both,1,ML,,54.65,40.99,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.4 MG/10ML SOLN,195386,CDM,636,RC,69374030510,NDC,,,facility,both,2.5,ML,,54.65,40.99,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.4 MG/10ML SOLN,195386,CDM,636,RC,69374030510,NDC,,,facility,both,2,ML,,54.65,40.99,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL 1 MG/10ML SOLN,195674,CDM,636,RC,69374030210,NDC,,,facility,both,0.2,ML,,25.6,19.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL 1 MG/10ML SOLN,195674,CDM,636,RC,69374030210,NDC,,,facility,both,2,ML,,30.95,23.21,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL 1 MG/10ML SOLN,195674,CDM,636,RC,69374030210,NDC,,,facility,both,5,ML,,39.85,29.89,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL 1 MG/10ML SOLN,195674,CDM,636,RC,69374030210,NDC,,,facility,both,0.5,ML,,26.5,19.88,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL 1 MG/10ML SOLN,195674,CDM,636,RC,69374030210,NDC,,,facility,both,6,ML,,42.8,32.1,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL 1 MG/10ML SOLN,195674,CDM,636,RC,69374030210,NDC,,,facility,both,3,ML,,33.9,25.42,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL 1 MG/10ML SOLN,195674,CDM,636,RC,69374030210,NDC,,,facility,both,1,ML,,28,21,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML SOLN 3 ML VIAL,195747,CDM,636,RC,J1303,HCPCS,25682002501,NDC,facility,both,10,ME,,526.38,394.78,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML SOLN 11 ML VIAL,195748,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,both,10,ME,,526.38,394.78,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1.3 % PTCH,195796,CDM,250,RC,59762070702,NDC,,,facility,both,1,UN,,48.8,36.6,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1.3 % PTCH,195796,CDM,250,RC,59762070701,NDC,,,facility,both,1,UN,,48.8,36.6,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1.3 % PTCH,195796,CDM,250,RC,82347040505,NDC,,,facility,both,1,UN,,46.5,34.88,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC SODIUM 1 % GEL 100 G TUBE,195809,CDM,250,RC,45802095301,NDC,,,facility,both,100,GR,,57.75,43.31,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC SODIUM 1 % GEL 100 G TUBE,195809,CDM,250,RC,69097052444,NDC,,,facility,both,100,GR,,62.4,46.8,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC SODIUM 1 % GEL 100 G TUBE,195809,CDM,250,RC,67815203,NDC,,,facility,both,100,GR,,60.2,45.15,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC SODIUM 1 % GEL 50 G TUBE,195809,CDM,250,RC,67815202,NDC,,,facility,both,50,GR,,50.9,38.18,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 20000 UNIT/ML IJ SOLN,196026,CDM,69131101,NDC,,,,,facility,both,1000,ML,,26,19.5,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 20000 UNIT/ML IJ SOLN,196026,CDM,69131110,NDC,,,,,facility,both,1000,ML,,27.84,20.88,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN,196026,CDM,636,RC,Q5106,HCPCS,69131110,NDC,facility,both,1000,UN,,32.66,24.5,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN 1 ML VIAL,196026,CDM,636,RC,Q5105,HCPCS,69131110,NDC,facility,both,1000,UN,,3.06,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 20000 UNIT/ML SOLN 1 ML VIAL,196026,CDM,636,RC,Q5106,HCPCS,69131110,NDC,facility,both,1000,UN,,31.94,23.95,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML SOLN,196606,CDM,636,RC,J0461,HCPCS,517100425,NDC,facility,both,0.01,ME,,1.58,1.18,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/10ML SOSY,196615,CDM,636,RC,J0171,HCPCS,409493301,NDC,facility,both,0.1,ME,,4.29,3.21,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/10ML SOSY,196615,CDM,636,RC,J0171,HCPCS,76329331801,NDC,facility,both,0.1,ME,,8.48,6.36,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML SOLN 20 ML VIAL,19699,CDM,250,RC,MHS1ML,HCPCS,409729973,NDC,facility,both,1,ML,,2.45,1.83,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML SOLN 50 ML VIAL,19699,CDM,250,RC,MHS1ML,HCPCS,69784023020,NDC,facility,both,1,ML,,12,9,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML SOLN 50 ML VIAL,19699,CDM,250,RC,MHS1ML,HCPCS,69784023010,NDC,facility,both,1,ML,,2.97,2.23,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML SOLN 50 ML VIAL,19699,CDM,250,RC,MHS1ML,HCPCS,409329905,NDC,facility,both,1,ML,,1.26,0.94,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 150 MG SOLR 1 EACH VIAL,197034,CDM,636,RC,Q5116,HCPCS,69030801,NDC,facility,both,10,ME,,205.76,154.32,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % 0.5 MEQ/ML SOLN,19705,CDM,250,RC,J3490,HCPCS,409555502,NDC,facility,both,1,ML,,41.94,31.45,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % 0.5 MEQ/ML SOLN,19705,CDM,250,RC,MHS1ML,HCPCS,63323008305,NDC,facility,both,1,ML,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % 0.5 MEQ/ML SOLN,19705,CDM,250,RC,J3490,HCPCS,63323008305,NDC,facility,both,1,ML,,13.17,9.88,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % 0.5 MEQ/ML SOLN,19705,CDM,250,RC,MHS1ML,HCPCS,409553414,NDC,facility,both,1,ML,,2.25,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % 0.5 MEQ/ML SOLN,19705,CDM,250,RC,FAMRXNC,HCPCS,409555502,NDC,facility,both,1,ML,,55.2,41.4,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % 0.5 MEQ/ML SOLN,19705,CDM,250,RC,MHS1ML,HCPCS,409555502,NDC,facility,both,1,ML,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % 0.5 MEQ/ML SOLN,19705,CDM,250,RC,FAMRXNC,HCPCS,63323008305,NDC,facility,both,1,ML,,49.8,37.35,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % IV SOLN,19705,CDM,63323008305,NDC,,,,,facility,both,1,ML,,26.27,19.71,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % IV SOLN,19705,CDM,409555512,NDC,,,,,facility,both,1,ML,,14,10.5,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % IV SOLN,19705,CDM,409555502,NDC,,,,,facility,both,1,ML,,55.2,41.4,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN,19708,CDM,250,RC,MHS1ML,HCPCS,409663714,NDC,facility,both,1,ML,,1.06,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN,19708,CDM,250,RC,MHS1ML,HCPCS,76329335201,NDC,facility,both,1,ML,,1.37,1.03,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN,19708,CDM,250,RC,MHS1ML,HCPCS,409662514,NDC,facility,both,1,ML,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN,19708,CDM,250,RC,MHS1ML,HCPCS,51754500104,NDC,facility,both,1,ML,,1.28,0.96,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN,19708,CDM,250,RC,MHS1ML,HCPCS,63323008950,NDC,facility,both,1,ML,,1.76,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN,19708,CDM,250,RC,MHS1ML,HCPCS,72572074001,NDC,facility,both,1,ML,,1.16,0.87,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN 50 ML SYRINGE,19708,CDM,250,RC,MHS1ML,HCPCS,76329335201,NDC,facility,both,1,ML,,1.14,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN 50 ML SYRINGE,19708,CDM,250,RC,MHS1ML,HCPCS,409663714,NDC,facility,both,1,ML,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN 50 ML SYRINGE,19708,CDM,250,RC,MHS1ML,HCPCS,69374091450,NDC,facility,both,1,ML,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,19708,CDM,250,RC,MHS1ML,HCPCS,63323008950,NDC,facility,both,1,ML,,1.16,0.87,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,19708,CDM,250,RC,MHS1ML,HCPCS,72572074001,NDC,facility,both,1,ML,,0.57,0.43,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,19708,CDM,250,RC,MHS1ML,HCPCS,409662502,NDC,facility,both,1,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,19708,CDM,250,RC,MHS1ML,HCPCS,51754500104,NDC,facility,both,1,ML,,0.69,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % SOLN 50 ML VIAL,19708,CDM,250,RC,MHS1ML,HCPCS,409662514,NDC,facility,both,1,ML,,0.7,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG TABS,19715,CDM,250,RC,66553000801,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG TABS,19715,CDM,250,RC,64980052810,NDC,,,facility,both,2,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG TABS,19715,CDM,250,RC,66553000801,NDC,,,facility,both,2,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG TABS,19715,CDM,250,RC,66553000801,NDC,,,facility,both,3,UN,,2.5,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG TABS,19715,CDM,250,RC,66553000801,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG TABS,19715,CDM,250,RC,64980052810,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG TABS,19715,CDM,250,RC,64980052810,NDC,,,facility,both,0.5,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
TRILACICLIB 300 MG SOLR 1 EACH VIAL,197167,CDM,636,RC,J1448,HCPCS,73462010101,NDC,facility,both,1,ME,,16.52,12.39,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL 0.45 % SOLN,19721,CDM,250,RC,MHS250ML,HCPCS,338004304,NDC,facility,both,250,ML,,4.36,3.27,,,,,,,,,,Gross Charge Type: Pharmacy
"0.45 % NACL 0.45 % SOLN 1,000 ML FLEX CONT",19721,CDM,250,RC,MHS250ML,HCPCS,338004304,NDC,facility,both,250,ML,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL 0.45 % SOLN 100 ML FLEX CONT,19721,CDM,250,RC,MHS250ML,HCPCS,338004918,NDC,facility,both,250,ML,,36.55,27.41,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL SOLN,19721,CDM,250,RC,MHS250ML,HCPCS,338004304,NDC,facility,both,250,ML,,4.37,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL SOLN,19721,CDM,250,RC,MHS250ML,HCPCS,990798509,NDC,facility,both,250,ML,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
"0.45 % NACL SOLN 1,000 ML FLEX CONT",19721,CDM,250,RC,MHS250ML,HCPCS,338004904,NDC,facility,both,250,ML,,10.1,7.58,,,,,,,,,,Gross Charge Type: Pharmacy
"0.45 % NACL SOLN 1,000 ML FLEX CONT",19721,CDM,250,RC,MHS250ML,HCPCS,338004304,NDC,facility,both,250,ML,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL SOLN 500 ML FLEX CONT,19721,CDM,250,RC,MHS250ML,HCPCS,338004303,NDC,facility,both,250,ML,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,264780510,NDC,,,facility,both,125,ML,,56.85,42.64,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,250,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,125,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,100,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,264780510,NDC,,,facility,both,100,ML,,57.33,43,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,300,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,338005403,NDC,,,facility,both,250,ML,,52.65,39.49,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,75,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,50,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,500,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,264780510,NDC,,,facility,both,75,ML,,57.9,43.42,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,60,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,264780510,NDC,,,facility,both,50,ML,,54.75,41.06,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,264780510,NDC,,,facility,both,500,ML,,57.11,42.83,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,150,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,338005403,NDC,,,facility,both,150,ML,,52.65,39.49,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,63323053075,NDC,,,facility,both,80,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,338005403,NDC,,,facility,both,500,ML,,52.65,39.49,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,338005403,NDC,,,facility,both,100,ML,,52.65,39.49,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,19725,CDM,250,RC,264780510,NDC,,,facility,both,150,ML,,56.32,42.24,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML SOLN,19726,CDM,636,RC,J7131,HCPCS,63323009330,NDC,facility,both,1,ML,,1.96,1.47,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML SOLN 100 ML VIAL,19726,CDM,636,RC,J7131,HCPCS,409114102,NDC,facility,both,1,ML,,23.7,17.78,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML SOLN 100 ML VIAL,19726,CDM,636,RC,J7131,HCPCS,63323009502,NDC,facility,both,1,ML,,1.47,1.11,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML SOLN 30 ML VIAL,19726,CDM,636,RC,J7131,HCPCS,63323018730,NDC,facility,both,1,ML,,23.88,17.91,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML SOLN 30 ML VIAL,19726,CDM,636,RC,J7131,HCPCS,63323009330,NDC,facility,both,1,ML,,3.99,2.99,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE (HYPERTONIC) 3 % NEBU,19731,CDM,250,RC,MHS5ML,HCPCS,487900330,NDC,facility,both,5,ML,,13.04,9.78,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE (HYPERTONIC) 3 % NEBU,19731,CDM,250,RC,MHS5ML,HCPCS,50190014263,NDC,facility,both,5,ML,,13.3,9.98,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % NEBU,19731,CDM,250,RC,MHS5ML,HCPCS,487900330,NDC,facility,both,5,ML,,13.05,9.79,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,77333083510,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,223176001,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,77333084410,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,904723961,NDC,,,facility,both,3,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,77333084410,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,77333084410,NDC,,,facility,both,2,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,77333083510,NDC,,,facility,both,3,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,223176001,NDC,,,facility,both,3,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,904723961,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,77333083510,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,904723961,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,77333083510,NDC,,,facility,both,2,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1 G TABS,19732,CDM,250,RC,223176001,NDC,,,facility,both,1,UN,,6.31,4.73,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,0.5,ML,,38.65,28.99,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,1.5,ML,,19.51,14.63,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,0.5,ML,,36.18,27.13,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,0.5,ML,,58.18,43.63,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,1,ML,,23.66,17.75,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,0.25,ML,,83.15,62.36,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,1,ML,,26.14,19.6,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,0.25,ML,,56.4,42.3,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,2.5,ML,,16.19,12.14,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,0.0625,ML,,32.85,24.64,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,0.25,ML,,63.35,47.51,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,6.12,ML,,15.67,11.75,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,7,ML,,15.84,11.88,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,8,ML,,15.72,11.79,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,6.36,ML,,15.61,11.71,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,3,ML,,17.83,13.37,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,7.53,ML,,15.32,11.49,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,0.5,ML,,38.65,28.99,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,6,ML,,16.03,12.02,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,5,ML,,16.34,12.26,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,6.02,ML,,16.08,12.06,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,7.01,ML,,15.86,11.9,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML AMPULE,197391,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,1,ML,,26.14,19.6,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,2.5,ML,,16.19,12.14,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,0.25,ML,,56.4,42.3,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,7,ML,,13.19,9.89,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,1,ML,,23.66,17.75,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,5,ML,,13.7,10.27,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 1 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,0.5,ML,,36.18,27.13,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 10 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,5.25,ML,,15.01,11.26,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 10 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,4,ML,,15.62,11.72,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 10 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,7.04,ML,,14.15,10.61,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 10 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,0.5,ML,,37.48,28.11,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 10 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,5,ML,,15.1,11.33,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 10 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,8.58,ML,,14.1,10.58,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 10 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,7.5,ML,,14.5,10.88,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 10 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,6,ML,,14.79,11.09,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN ACETATE PF 4 MCG/ML SOLN 10 ML VIAL,197391,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,7,ML,,14.58,10.93,,,,,,,,,,Gross Charge Type: Pharmacy
D-ALPHA TOCOPHEROL 180 MG (400 UNITS) CAPS,197623,CDM,250,RC,77333095110,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
D-ALPHA TOCOPHEROL 180 MG (400 UNITS) CAPS,197623,CDM,250,RC,77333095110,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP,197904,CDM,250,RC,62541040210,NDC,,,facility,both,6,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP,197904,CDM,250,RC,62541040210,NDC,,,facility,both,1,UN,,10,7.5,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP,197904,CDM,250,RC,62541040210,NDC,,,facility,both,4,UN,,4.31,3.23,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP,197904,CDM,250,RC,62541040210,NDC,,,facility,both,2,UN,,6.29,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP,197904,CDM,250,RC,62541040210,NDC,,,facility,both,3,UN,,5.01,3.76,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP 1 CAPSULE BLISTER,197904,CDM,250,RC,62541040210,NDC,,,facility,both,1,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP 1 CAPSULE BLISTER,197904,CDM,250,RC,62541040210,NDC,,,facility,both,2,UN,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP 1 CAPSULE BLISTER,197904,CDM,250,RC,62541040210,NDC,,,facility,both,3,UN,,2.33,1.75,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP 100 EACH BOTTLE,197904,CDM,250,RC,62541040210,NDC,,,facility,both,4,UN,,2.11,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP 100 EACH BOTTLE,197904,CDM,250,RC,62541040210,NDC,,,facility,both,18,UN,,2.48,1.86,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP 100 EACH BOTTLE,197904,CDM,250,RC,62541040210,NDC,,,facility,both,3,UN,,2.33,1.75,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP 100 EACH BOTTLE,197904,CDM,250,RC,62541040210,NDC,,,facility,both,1,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 4200-14200 UNITS CPEP 100 EACH BOTTLE,197904,CDM,250,RC,62541040210,NDC,,,facility,both,2,UN,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,7,UN,,11.86,8.9,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,2,UN,,15.12,11.34,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,0.2,UN,,10.3,7.72,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,0.8,UN,,18.05,13.54,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,5,UN,,11.76,8.82,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,3,UN,,13.47,10.11,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,6,UN,,11.58,8.69,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,4,UN,,13,9.75,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,0.4,UN,,12.75,9.56,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,1,UN,,19.76,14.82,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP,197906,CDM,250,RC,62541040510,NDC,,,facility,both,1.2,UN,,10.72,8.04,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP 1 CAPSULE BLISTER,197906,CDM,250,RC,62541040510,NDC,,,facility,both,2,UN,,14.72,11.04,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP 1 CAPSULE BLISTER,197906,CDM,250,RC,62541040510,NDC,,,facility,both,3,UN,,12.98,9.74,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP 1 CAPSULE BLISTER,197906,CDM,250,RC,62541040510,NDC,,,facility,both,1,UN,,19.35,14.51,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP 100 EACH BOTTLE,197906,CDM,250,RC,62541040510,NDC,,,facility,both,3,UN,,12.98,9.74,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP 100 EACH BOTTLE,197906,CDM,250,RC,62541040510,NDC,,,facility,both,1,UN,,19.48,14.61,,,,,,,,,,Gross Charge Type: Pharmacy
PANCRELIPASE (LIP-PROT-AMYL) 21000-54700 UNITS CPEP 100 EACH BOTTLE,197906,CDM,250,RC,62541040510,NDC,,,facility,both,2,UN,,14.82,11.11,,,,,,,,,,Gross Charge Type: Pharmacy
DOSTARLIMAB-GXLY 500 MG/10ML SOLN 10 ML VIAL,198084,CDM,636,RC,J9272,HCPCS,173089803,NDC,facility,both,10,ME,,603.15,452.37,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLMITRIPTAN 2.5 MG TABS,19813,CDM,250,RC,68462049776,NDC,,,facility,both,1,UN,,15.95,11.96,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLMITRIPTAN 2.5 MG TABS,19813,CDM,250,RC,68462049776,NDC,,,facility,both,2,UN,,11.5,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
BALOXAVIR MARBOXIL(40 MG DOSE) 1 X 40 MG TBPK,198925,CDM,250,RC,50242086001,NDC,,,facility,both,1,UN,,237.3,177.98,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML SUSY,199114,CDM,636,RC,90677,HCPCS,5200002,NDC,facility,both,1,EA,,461.36,346.02,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML SUSY,199114,CDM,636,RC,90677,HCPCS,5200010,NDC,facility,both,1,EA,,418.9,314.18,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML SUSY,199114,CDM,636,RC,90677,HCPCS,5200001,NDC,facility,both,1,EA,,421.5,316.13,,,,,,,,,,Gross Charge Type: Pharmacy
ANIFROLUMAB-FNIA 300 MG/2ML SOLN 2 ML VIAL,199144,CDM,636,RC,J0491,HCPCS,310304000,NDC,facility,both,1,ME,,41.29,30.97,,,,,,,,,,Gross Charge Type: Pharmacy
AVALGLUCOSIDASE ALFA-NGPT 10 MG/ML SOLR 1 EACH VIAL,199195,CDM,636,RC,J0219,HCPCS,58468042601,NDC,facility,both,4,ME,,177.61,133.2,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.58,ML,,65.97,49.48,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.49,ML,,62.6,46.95,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.38,ML,,60.3,45.22,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.42,ML,,60.06,45.04,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.56,ML,,65.26,48.95,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.88,ML,,76.65,57.49,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.82,ML,,74.7,56.02,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.66,ML,,68.31,51.24,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.33,ML,,58.7,44.02,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.91,ML,,75.78,56.83,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.61,ML,,67.39,50.54,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.8,ML,,72.66,54.49,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.5,ML,,63.62,47.71,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.76,ML,,70.26,52.7,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.39,ML,,59.25,44.44,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.84,ML,,75.35,56.51,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.55,ML,,63.65,47.74,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.51,ML,,63.4,47.55,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,1,ML,,77.31,57.98,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.94,ML,,78.6,58.95,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.44,ML,,62.03,46.52,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.93,ML,,75.75,56.81,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.53,ML,,63.05,47.29,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.45,ML,,61.44,46.08,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.69,ML,,70.45,52.84,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.34,ML,,57.6,43.2,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.37,ML,,60,45,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.41,ML,,60.48,45.36,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.59,ML,,65.39,49.04,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.48,ML,,62.79,47.09,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.63,ML,,66.16,49.62,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.6,ML,,66.3,49.72,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.57,ML,,64.97,48.72,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.46,ML,,61.05,45.79,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.36,ML,,59.65,44.74,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.35,ML,,57.98,43.48,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.43,ML,,61.17,45.88,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.89,ML,,76.95,57.71,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.65,ML,,67.82,50.87,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.98,ML,,79.9,59.92,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.83,ML,,73.88,55.41,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.68,ML,,68.38,51.29,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.54,ML,,64.08,48.06,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.31,ML,,56.7,42.52,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.27,ML,,55.5,41.62,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.64,ML,,68.15,51.11,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.79,ML,,72.1,54.08,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.87,ML,,76.3,57.22,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.95,ML,,78.9,59.18,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.47,ML,,62.36,46.77,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.81,ML,,72.72,54.54,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.78,ML,,70.25,52.69,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.85,ML,,72.82,54.61,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.62,ML,,68.15,51.11,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.67,ML,,69.8,52.35,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.72,ML,,68.5,51.38,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.77,ML,,73.05,54.79,,,,,,,,,,Gross Charge Type: Pharmacy
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML SOLN 1 ML VIAL,199266,CDM,250,RC,517930225,NDC,,,facility,both,0.86,ML,,74.25,55.69,,,,,,,,,,Gross Charge Type: Pharmacy
SORBITOL 70 % SOLN 480 ML BOTTLE,19932,CDM,250,RC,10135013708,NDC,,,facility,both,60,ML,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION PLANT BASED (SOY) 20 % EMUL,199448,CDM,250,RC,MHS250ML,HCPCS,264446030,NDC,facility,both,250,ML,,89.69,67.27,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION PLANT BASED (SOY) 20 % EMUL,199448,CDM,250,RC,MHS250ML,HCPCS,338051958,NDC,facility,both,250,ML,,52.22,39.17,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULS PLANT BASE(SOY/OLIV) 20 % EMUL,199449,CDM,250,RC,MHS250ML,HCPCS,338954006,NDC,facility,both,250,ML,,72.11,54.08,,,,,,,,,,Gross Charge Type: Pharmacy
ETHIODIZED OIL 480 MG/ML OIL,199457,CDM,250,RC,67684190102,NDC,,,facility,both,55,ML,,2766.7,2075.02,,,,,,,,,,Gross Charge Type: Pharmacy
ETHIODIZED OIL 480 MG/ML OIL,199457,CDM,250,RC,67684190102,NDC,,,facility,both,7.5,ML,,2263.7,1697.78,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE HCL 10 MG/ML SOLN,199458,CDM,250,RC,MHS1ML,HCPCS,121064616,NDC,facility,both,1,ML,,0.47,0.35,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE PF 4 MG/ML SOLN,199468,CDM,636,RC,J2270,HCPCS,641612525,NDC,facility,both,10,ME,,39.6,29.7,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 SUSY,199472,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,both,0.5,ML,,34.11,25.58,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS IMMUNE GLOBULIN 250 UNIT/ML SOSY,199475,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,both,250,UN,,1302.2,976.65,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5ML SOSY,199477,CDM,636,RC,90371,HCPCS,13533063603,NDC,facility,both,1,ML,,256,192,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B IMMUNE GLOBULIN 312 UNIT/ML SOLN,199481,CDM,636,RC,90371,HCPCS,70257005151,NDC,facility,both,1,ML,,245.86,184.39,,,,,,,,,,Gross Charge Type: Pharmacy
THYROTROPIN ALFA 0.9 MG IM SOLR,199485,CDM,58468003001,NDC,,,,,facility,both,0.9,EA,,4111.73,3083.79,,,,,,,,,,Gross Charge Type: Pharmacy
THYROTROPIN ALFA 0.9 MG IM SOLR,199485,CDM,58468003002,NDC,,,,,facility,both,0.9,EA,,4756.7,3567.52,,,,,,,,,,Gross Charge Type: Pharmacy
THYROTROPIN ALFA SOLR,199485,CDM,636,RC,J3240,HCPCS,58468003002,NDC,facility,both,0.9,ME,,4703.83,3527.87,,,,,,,,,,Gross Charge Type: Pharmacy
CHONDROITIN/SODIUM HYALURONATE 20-15 MG/0.5ML SOSY,199494,CDM,250,RC,MHS1ML,HCPCS,8065183905,NDC,facility,both,1,ML,,214.15,160.61,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMIN E 90 MG (200 UNIT) CAPS,199497,CDM,250,RC,54629020001,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 10 MG/ML SOLN 12 ML VIAL,199640,CDM,636,RC,J9299,HCPCS,3375614,NDC,facility,both,1,ME,,80.44,60.33,,,,,,,,,,Gross Charge Type: Pharmacy
TISOTUMAB VEDOTIN-TFTV 10 MG/ML SOLR 1 EACH VIAL,199746,CDM,636,RC,J9273,HCPCS,51144000301,NDC,facility,both,1,ME,,442.34,331.75,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM THIOSULFATE 250 MG/ML SOLN,199800,CDM,636,RC,J0208,HCPCS,60267070550,NDC,facility,both,100,ME,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM THIOSULFATE 250 MG/ML SOLN 50 ML VIAL,199800,CDM,636,RC,J0208,HCPCS,60267070550,NDC,facility,both,100,ME,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,53489014305,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,51079010320,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,53489014305,NDC,,,facility,both,2,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,60687046501,NDC,,,facility,both,1,UN,,6.77,5.08,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,63739054410,NDC,,,facility,both,2,UN,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,53489014305,NDC,,,facility,both,4,UN,,2.1,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,60687046501,NDC,,,facility,both,2,UN,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,16714008401,NDC,,,facility,both,4,UN,,1.86,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,63739054410,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,63739054410,NDC,,,facility,both,4,UN,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,51079010320,NDC,,,facility,both,2,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,51079010320,NDC,,,facility,both,4,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,16714008401,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 25 MG TABS,20106,CDM,250,RC,53489014305,NDC,,,facility,both,3,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 25 MG TABS,2011,CDM,250,RC,51079075920,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 25 MG TABS,2011,CDM,250,RC,51079075920,NDC,,,facility,both,2,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 25 MG TABS,2011,CDM,250,RC,51079075920,NDC,,,facility,both,1.5,UN,,3.82,2.87,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 25 MG TABS,2011,CDM,250,RC,51079075920,NDC,,,facility,both,3,UN,,2.93,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 25 MG TABS,2011,CDM,250,RC,51079075920,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 25 MG TABS,2011,CDM,250,RC,904718761,NDC,,,facility,both,2,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 25 MG TABS,2011,CDM,250,RC,51079075920,NDC,,,facility,both,4,UN,,2.29,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 0.25 MG TABS,20116,CDM,250,RC,904637361,NDC,,,facility,both,4,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 0.25 MG TABS,20116,CDM,250,RC,904637361,NDC,,,facility,both,3,UN,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 0.25 MG TABS,20116,CDM,250,RC,904637361,NDC,,,facility,both,1,UN,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 0.25 MG TABS,20116,CDM,250,RC,904637361,NDC,,,facility,both,2,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
INCLISIRAN 284 MG/1.5ML SOSY,201165,CDM,636,RC,J1306,HCPCS,78100060,NDC,facility,both,1,ME,,28.48,21.36,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,68462025501,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,8,UN,,1.77,1.33,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,3,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,2,UN,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,68462025501,NDC,,,facility,both,2,UN,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,5,UN,,2.37,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,0.5,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,68462025501,NDC,,,facility,both,6,UN,,1.52,1.14,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,1,UN,,8.26,6.2,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,1.5,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,6,UN,,2.11,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,68462025501,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,68462025501,NDC,,,facility,both,3,UN,,2.73,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,68462025501,NDC,,,facility,both,4,UN,,2.16,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,68462025501,NDC,,,facility,both,12,UN,,0.89,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,12,UN,,1.42,1.06,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE 1 MG TABS,20118,CDM,250,RC,904637461,NDC,,,facility,both,4,UN,,2.76,2.07,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 200 MG/ML SOLN 10 ML VIAL,201196,CDM,636,RC,J9073,HCPCS,50742052110,NDC,facility,both,5,ME,,12.34,9.25,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 200 MG/ML SOLN 10 ML VIAL,201196,CDM,636,RC,J9070,HCPCS,50742052110,NDC,facility,both,5,ME,,245.8,184.35,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 50 MG TABS,2012,CDM,250,RC,51079068420,NDC,,,facility,both,2,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 50 MG TABS,2012,CDM,250,RC,51079068420,NDC,,,facility,both,1,UN,,6.01,4.51,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 50 MG TABS,2012,CDM,250,RC,51079068420,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
EFGARTIGIMOD ALFA-FCAB 20 MG/ML SOLN 20 ML VIAL,201245,CDM,636,RC,J9332,HCPCS,73475304105,NDC,facility,both,2,ME,,76.32,57.24,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG/10ML LIQD,201270,CDM,250,RC,121187000,NDC,,,facility,both,10,ML,,9.46,7.1,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG/20ML SOLN 20 ML VIAL,201429,CDM,636,RC,J9304,HCPCS,42367053133,NDC,facility,both,10,ME,,190.62,142.96,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER SOLN,20224,CDM,250,RC,MHS1ML,HCPCS,338001304,NDC,facility,both,1,ML,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER SOLN 1,000 ML FLEX CONT",20224,CDM,250,RC,MHS1ML,HCPCS,338001304,NDC,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER SOLN 1,000 ML FLEX CONT",20224,CDM,250,RC,MHS1ML,HCPCS,264785000,NDC,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER SOLN 10 ML VIAL,20224,CDM,250,RC,MHS1ML,HCPCS,409488710,NDC,facility,both,1,ML,,1.19,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER SOLN 10 ML VIAL,20224,CDM,250,RC,MHS1ML,HCPCS,72572074701,NDC,facility,both,1,ML,,1.33,1,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER SOLN 100 ML VIAL,20224,CDM,250,RC,MHS1ML,HCPCS,409488799,NDC,facility,both,1,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER SOLN 20 ML VIAL,20224,CDM,250,RC,MHS1ML,HCPCS,409488720,NDC,facility,both,1,ML,,1.56,1.17,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER SOLN 50 ML VIAL,20224,CDM,250,RC,MHS1ML,HCPCS,409488750,NDC,facility,both,1,ML,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER (BOTTLE) SOLN,20225,CDM,250,RC,990713909,NDC,,,facility,both,1000,ML,,27.25,20.44,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER (BOTTLE) SOLN 1,000 ML FLEX CONT",20225,CDM,250,RC,990713909,NDC,,,facility,both,1000,ML,,27.25,20.44,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER (BOTTLE) SOLN 500 ML FLEX CONT,20225,CDM,250,RC,990613903,NDC,,,facility,both,450,ML,,25.45,19.09,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER (BOTTLE) SOLN 500 ML FLEX CONT,20225,CDM,250,RC,990613903,NDC,,,facility,both,300,ML,,24.2,18.15,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER (BOTTLE) SOLN 500 ML FLEX CONT,20225,CDM,250,RC,990613903,NDC,,,facility,both,500,ML,,26.3,19.72,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB-RELATLIMAB-RMBW 12-4 MG/ML SOLN 20 ML VIAL,202640,CDM,636,RC,J9298,HCPCS,3712511,NDC,facility,both,3,ME,,469.25,351.94,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB-RELATLIMAB-RMBW 12-4 MG/ML SOLN 20 ML VIAL,202640,CDM,636,RC,C9399,HCPCS,3712511,NDC,facility,both,3,ME,,35830.35,26872.76,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM 2 G SOLR,202645,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,both,500,ME,,14.09,10.57,,,,,,,,,,Gross Charge Type: Pharmacy
"PENICILLIN G BENZATHINE 1,200,000 UNITS/2 ML SUSY",202661,CDM,636,RC,J0561,HCPCS,60793070110,NDC,facility,both,100000,UN,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,202661,CDM,60793070110,NDC,,,,,facility,both,100000,ML,,46,34.5,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B IMMUNE GLOBULIN 312 UNIT/ML SOLN,202662,CDM,636,RC,70257005151,NDC,,,facility,both,3.88,ML,,1175.3,881.48,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE BIT-HOMATROP MBR 5-1.5 MG/5ML SOLN,202664,CDM,250,RC,472103016,NDC,,,facility,both,5,ML,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE BIT-HOMATROP MBR 5-1.5 MG/5ML SOLN,202664,CDM,250,RC,472103016,NDC,,,facility,both,10,ML,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SOLN,202670,CDM,636,RC,J1815,HCPCS,2753301,NDC,facility,both,5,UN,,25.35,19.01,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,641602225,NDC,,,facility,both,2,ML,,31.5,23.62,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,67457043322,NDC,,,facility,both,4,ML,,18.55,13.91,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,63323073912,NDC,,,facility,both,0.34,ML,,29.95,22.46,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,641602225,NDC,,,facility,both,1.7,ML,,31.5,23.62,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,641602225,NDC,,,facility,both,4,ML,,18.98,14.23,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,641602225,NDC,,,facility,both,1,ML,,31.5,23.62,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,67457043322,NDC,,,facility,both,1,ML,,31.05,23.29,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,641602225,NDC,,,facility,both,0.61,ML,,31.5,23.62,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,67457043322,NDC,,,facility,both,2,ML,,31.05,23.29,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,63323073912,NDC,,,facility,both,2,ML,,29.95,22.46,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,67457043322,NDC,,,facility,both,1.16,ML,,31.05,23.29,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,63323073912,NDC,,,facility,both,4,ML,,17.42,13.07,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,63323073912,NDC,,,facility,both,1,ML,,29.95,22.46,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,67457043322,NDC,,,facility,both,0.6,ML,,31.05,23.29,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN,202672,CDM,250,RC,641602225,NDC,,,facility,both,0.9,ML,,31.5,23.62,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN 2 ML VIAL,202672,CDM,250,RC,641602225,NDC,,,facility,both,2,ML,,31.5,23.62,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN 2 ML VIAL,202672,CDM,250,RC,63323073912,NDC,,,facility,both,2,ML,,29.95,22.46,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 10 MG/ML SOLN 2 ML VIAL,202672,CDM,250,RC,641602225,NDC,,,facility,both,4,ML,,18.98,14.23,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 30 MG/0.3ML SOSY,202673,CDM,636,RC,J1650,HCPCS,16714000610,NDC,facility,both,10,ME,,14.51,10.88,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 30 MG/0.3ML SOSY,202673,CDM,636,RC,J1650,HCPCS,63323053383,NDC,facility,both,10,ME,,14.67,11,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 40 MG/0.4ML SOSY,202674,CDM,636,RC,J1650,HCPCS,63323053598,NDC,facility,both,10,ME,,12.71,9.53,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 40 MG/0.4ML SOSY,202674,CDM,636,RC,J1650,HCPCS,16714001610,NDC,facility,both,10,ME,,12.4,9.3,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 60 MG/0.6ML SOSY,202675,CDM,636,RC,J1650,HCPCS,16714002610,NDC,facility,both,10,ME,,10.05,7.54,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 60 MG/0.6ML SOSY,202675,CDM,636,RC,J1650,HCPCS,63323060788,NDC,facility,both,10,ME,,10.42,7.82,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 80 MG/0.8ML SOSY,202676,CDM,636,RC,J1650,HCPCS,63323053190,NDC,facility,both,10,ME,,8.51,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 80 MG/0.8ML SOSY,202676,CDM,636,RC,J1650,HCPCS,63323058499,NDC,facility,both,10,ME,,8.14,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 100 MG/1 ML SOSY,202677,CDM,636,RC,J1650,HCPCS,63323060584,NDC,facility,both,10,ME,,7.44,5.58,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 100 MG/1 ML SOSY,202677,CDM,636,RC,J1650,HCPCS,16714004610,NDC,facility,both,10,ME,,7.18,5.39,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 100 MG/1 ML SOSY,202677,CDM,636,RC,J1650,HCPCS,63323058621,NDC,facility,both,10,ME,,10.19,7.64,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 100 MG/1 ML SOSY,202677,CDM,636,RC,J1650,HCPCS,955101010,NDC,facility,both,10,ME,,10.42,7.82,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 120 MG/0.8ML SOSY,202678,CDM,636,RC,J1650,HCPCS,16714005610,NDC,facility,both,10,ME,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 120 MG/0.8ML SOSY,202678,CDM,636,RC,J1650,HCPCS,955101210,NDC,facility,both,10,ME,,9.6,7.2,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 150 MG/1 ML SOSY,202679,CDM,636,RC,J1650,HCPCS,63323053784,NDC,facility,both,10,ME,,5.68,4.26,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN SODIUM 150 MG/1 ML SOSY,202679,CDM,636,RC,J1650,HCPCS,16714006610,NDC,facility,both,10,ME,,5.52,4.14,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTHERIA, TETANUS, ACELLULAR PERTUSSIS, HEPATITIS B, INACTIVATED POLIO VACCINE SUSY",202707,CDM,636,RC,90723,HCPCS,58160081152,NDC,facility,both,0.5,ML,,58,43.5,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,636,RC,J1836,HCPCS,47335099301,NDC,facility,both,10,ME,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,250,RC,J1836,HCPCS,409015224,NDC,facility,both,10,ME,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,636,RC,J1836,HCPCS,80830246501,NDC,facility,both,10,ME,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,250,RC,J1836,HCPCS,338105548,NDC,facility,both,10,ME,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,636,RC,J1836,HCPCS,264553532,NDC,facility,both,10,ME,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,636,RC,J1836,HCPCS,409015224,NDC,facility,both,10,ME,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,250,RC,409015224,NDC,,,facility,both,10,ME,,36.55,27.41,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,250,RC,338105548,NDC,,,facility,both,10,ME,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,636,RC,J1836,HCPCS,338105548,NDC,facility,both,10,ME,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG/100ML SOLN,202724,CDM,250,RC,MHS1ML,HCPCS,409015224,NDC,facility,both,10,ME,,0.37,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-AYOW 300 MCG/0.5 ML SOSY,202768,CDM,636,RC,Q5125,HCPCS,70121156807,NDC,facility,both,0.5,ML,,1.39,1.04,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-AYOW 300 MCG/0.5 ML SOSY,202768,CDM,636,RC,Q5125,HCPCS,70121156801,NDC,facility,both,0.5,ML,,1.39,1.04,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-AYOW 480 MCG/0.8 ML SOSY,202770,CDM,636,RC,Q5125,HCPCS,70121157001,NDC,facility,both,0.8,ML,,1.37,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-AYOW 480 MCG/0.8 ML SOSY,202770,CDM,636,RC,Q5125,HCPCS,70121157007,NDC,facility,both,0.8,ML,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 100-50 MCG/ACT AEPB 14 EACH DISP PACK,202906,CDM,250,RC,173069504,NDC,,,facility,both,14,UN,,220.75,165.56,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250-50 MCG/ACT AEPB 14 EACH DISP PACK,202908,CDM,250,RC,173069604,NDC,,,facility,both,14,UN,,188.2,141.15,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250-50 MCG/ACT AEPB 60 EACH DISP PACK,202908,CDM,250,RC,173069600,NDC,,,facility,both,60,UN,,569.2,426.9,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 500-50 MCG/ACT AEPB 14 EACH DISP PACK,202909,CDM,250,RC,173069704,NDC,,,facility,both,14,UN,,239.15,179.36,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 20 MCG/DAY IU IUD,202967,CDM,50419042301,NDC,,,,,facility,both,52,EA,,1829.85,1372.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 20 MCG/DAY IUD,202967,CDM,636,RC,J7298,HCPCS,50419042301,NDC,facility,both,52,ME,,2240.13,1680.1,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 20.1 MCG/DAY IU IUD,202968,CDM,23585801,NDC,,,,,facility,both,52,EA,,1774.75,1331.06,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Intensive Care Pediatrics,2030000001,CDM,203,RC,,,,,facility,both,,,,4530,3397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Room Intensive Care Psychiatric,2040000001,CDM,204,RC,,,,,facility,both,,,,3713,2784.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
RISANKIZUMAB-RZAA 60 MG/ML SOLN 10 ML VIAL,204046,CDM,636,RC,J2327,HCPCS,74501501,NDC,facility,both,1,ME,,36.43,27.32,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA 60 MG/ML SOLN 10 ML VIAL,204046,CDM,636,RC,J3590,HCPCS,74501501,NDC,facility,both,1,ME,,22529.1,16896.82,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE 20 MG/ML SOLN,20428,CDM,636,RC,J0330,HCPCS,43598066625,NDC,facility,both,20,ME,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
"ESTROGENS, CONJUGATED 0.625 MG/GM CREA 30 G TUBE",204765,CDM,250,RC,46087221,NDC,,,facility,both,30,GR,,638.07,478.55,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SUCCINATE 100 MG SOLR,204778,CDM,636,RC,J1720,HCPCS,9082501,NDC,facility,both,100,ME,,84.15,63.11,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SUCCINATE 100 MG SOLR,204778,CDM,636,RC,J1720,HCPCS,9001104,NDC,facility,both,100,ME,,74.11,55.58,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SUCCINATE 100 MG SOLR 1 EACH VIAL,204778,CDM,636,RC,J1720,HCPCS,9082501,NDC,facility,both,100,ME,,84.15,63.11,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SUCCINATE 100 MG SOLR 1 EACH VIAL,204778,CDM,636,RC,J1720,HCPCS,9001104,NDC,facility,both,100,ME,,44.55,33.41,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SODIUM SUCCINATE PF 250 MG SOLR,204779,CDM,636,RC,J1720,HCPCS,9001306,NDC,facility,both,100,ME,,59.52,44.64,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 25 MG TABS,20489,CDM,250,RC,904663861,NDC,,,facility,both,1,UN,,7.22,5.42,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 25 MG TABS,20489,CDM,250,RC,904663861,NDC,,,facility,both,3,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 25 MG TABS,20489,CDM,250,RC,904663861,NDC,,,facility,both,4,UN,,2.49,1.87,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 25 MG TABS,20489,CDM,250,RC,904663861,NDC,,,facility,both,1.5,UN,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 25 MG TABS,20489,CDM,250,RC,904663861,NDC,,,facility,both,2,UN,,4.38,3.29,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 25 MG TABS,20489,CDM,250,RC,904663861,NDC,,,facility,both,0.5,UN,,6.72,5.04,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,1.5,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,0.875,UN,,2.35,1.76,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,67877025001,NDC,,,facility,both,1,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,16714045401,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,68180044701,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,67877025001,NDC,,,facility,both,4,UN,,1.95,1.46,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,1.125,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,4,UN,,2.84,2.13,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,3,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,68180044701,NDC,,,facility,both,2,UN,,3.78,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,1,UN,,6.98,5.24,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,16714045401,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,5,UN,,2.44,1.83,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,0.5,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,1.25,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,16714045401,NDC,,,facility,both,2,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,904664061,NDC,,,facility,both,2,UN,,4.75,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,68180044701,NDC,,,facility,both,1,UN,,5.37,4.03,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,68180044701,NDC,,,facility,both,3,UN,,2.77,2.07,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,67877025001,NDC,,,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,16714045401,NDC,,,facility,both,3,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG TABS,20491,CDM,250,RC,67877025001,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,60687036001,NDC,,,facility,both,1,UN,,9.95,7.46,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,904664161,NDC,,,facility,both,2.5,UN,,4.22,3.16,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,904664161,NDC,,,facility,both,1.5,UN,,5.38,4.03,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,904664161,NDC,,,facility,both,1,UN,,9.7,7.28,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,60687036001,NDC,,,facility,both,2,UN,,6.08,4.56,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,904664161,NDC,,,facility,both,3,UN,,4.53,3.4,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,904664161,NDC,,,facility,both,4,UN,,3.85,2.89,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,904664161,NDC,,,facility,both,2,UN,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,904664161,NDC,,,facility,both,5,UN,,3.41,2.56,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG TABS,20492,CDM,250,RC,904664161,NDC,,,facility,both,0.5,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML SOLN 10 ML VIAL,20507,CDM,250,RC,MHS1ML,HCPCS,703951403,NDC,facility,both,1,ML,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG TABS,20509,CDM,250,RC,50268072815,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG TABS,20509,CDM,250,RC,65862041901,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG TABS,20509,CDM,250,RC,50268072815,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG TABS,20509,CDM,250,RC,50268072815,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VACCINET 20 MCG/ML SUSY,205182,CDM,636,RC,90746,HCPCS,58160082152,NDC,facility,both,1,ML,,126.44,94.83,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 50 MG/ML SOSY,205183,CDM,636,RC,J9395,HCPCS,70860021174,NDC,facility,both,25,ME,,143.61,107.71,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 50 MG/ML SOSY,205183,CDM,636,RC,J9395,HCPCS,16714007002,NDC,facility,both,25,ME,,28.16,21.12,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VACCINE 10 MCG/0.5ML SUSY,205186,CDM,636,RC,58160082052,NDC,,,facility,both,1,ML,,79.2,59.4,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VACCINE 10 MCG/0.5ML SUSY,205186,CDM,636,RC,90744,HCPCS,58160082052,NDC,facility,both,1,ML,,79.22,59.42,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG TABS,20521,CDM,250,RC,59762500005,NDC,,,facility,both,3,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG TABS,20521,CDM,250,RC,59762500005,NDC,,,facility,both,2,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG TABS,20521,CDM,250,RC,59762500005,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG TBEC,20522,CDM,250,RC,59762010405,NDC,,,facility,both,2,UN,,4.15,3.11,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 200 MG/10ML LIQD,205343,CDM,250,RC,121148800,NDC,,,facility,both,5,ML,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 200 MG/10ML LIQD,205343,CDM,250,RC,121148800,NDC,,,facility,both,10,ML,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 200 MG/10ML LIQD,205343,CDM,250,RC,121148800,NDC,,,facility,both,15,ML,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE 1 % SOLN,205381,CDM,636,RC,Q9968,HCPCS,54288014701,NDC,facility,both,1,ME,,6.04,4.53,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE 1 % SOLN 10 ML VIAL,205381,CDM,636,RC,Q9968,HCPCS,54288014701,NDC,facility,both,1,ME,,4.21,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIDOSE WITH SORBITOL 50 GM/240ML SUSP,205390,CDM,250,RC,66689020308,NDC,,,facility,both,240,ML,,53.35,40.01,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-UMECLIDIN-VILANT 100-62.5-25 MCG/ACT AEPB,205445,CDM,250,RC,173088714,NDC,,,facility,both,1,UN,,21.55,16.16,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-UMECLIDIN-VILANT 100-62.5-25 MCG/ACT AEPB,205445,CDM,250,RC,173088710,NDC,,,facility,both,1,UN,,29.85,22.39,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARB-CHOLECALCIFEROL 500-5 MG-MCG TABS,205563,CDM,250,RC,904546092,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARB-CHOLECALCIFEROL 500-5 MG-MCG TABS,205563,CDM,250,RC,904546092,NDC,,,facility,both,2,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG TABS,205578,CDM,250,RC,536322301,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG TABS,205578,CDM,250,RC,536322301,NDC,,,facility,both,2,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG TABS,205578,CDM,250,RC,536322301,NDC,,,facility,both,3,UN,,2.25,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 75 MG TABS,20568,CDM,250,RC,31722072930,NDC,,,facility,both,4,UN,,2.41,1.81,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 75 MG TABS,20568,CDM,250,RC,31722072930,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 75 MG TABS,20568,CDM,250,RC,31722072930,NDC,,,facility,both,2,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 75 MG TABS,20568,CDM,250,RC,31722072930,NDC,,,facility,both,3,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG TABS,20569,CDM,250,RC,42658012204,NDC,,,facility,both,2,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG TABS,20569,CDM,250,RC,42658012204,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG TABS,20569,CDM,250,RC,42658012204,NDC,,,facility,both,1.5,UN,,3.82,2.87,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG TABS,20569,CDM,250,RC,42658012204,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG TABS,20569,CDM,250,RC,31722073090,NDC,,,facility,both,1,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG TABS,20570,CDM,250,RC,50268044211,NDC,,,facility,both,0.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG TABS,20570,CDM,250,RC,31722073190,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG TABS,20570,CDM,250,RC,50268044211,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG TABS,20570,CDM,250,RC,31722073130,NDC,,,facility,both,0.5,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG TABS,20570,CDM,250,RC,31722073130,NDC,,,facility,both,1,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG TABS,20570,CDM,250,RC,31722073190,NDC,,,facility,both,1,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML SOLN,205974,CDM,255,RC,A9579,HCPCS,270702038,NDC,facility,both,1,ML,,14.89,11.17,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML SOLN,205974,CDM,636,RC,A9579,HCPCS,270702038,NDC,facility,both,1,ML,,14.68,11.01,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML SOLN,205974,CDM,636,RC,A9579,HCPCS,270702540,NDC,facility,both,1,ML,,14.96,11.22,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML SOLN,205974,CDM,255,RC,A9579,HCPCS,270703042,NDC,facility,both,1,ML,,14.27,10.7,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML SOLN,205974,CDM,255,RC,A9579,HCPCS,270702540,NDC,facility,both,1,ML,,15.07,11.3,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML SOLN,205974,CDM,636,RC,A9579,HCPCS,270703042,NDC,facility,both,1,ML,,14.28,10.71,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Room Intermediate Care,2060000001,CDM,206,RC,,,,,facility,both,,,,3226,2419.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
PHARMACY 636,206160,CDM,636,RC,j9347,HCPCS,310450525,NDC,facility,both,1,ME,,8837.1,6627.82,,,,,,,,,,Gross Charge Type: Pharmacy
TREMELIMUMAB-ACTL 20 MG/ML SOLN 1.25 ML VIAL,206160,CDM,636,RC,J9298,HCPCS,310450525,NDC,facility,both,1,ME,,8837.1,6627.82,,,,,,,,,,Gross Charge Type: Pharmacy
TREMELIMUMAB-ACTL 20 MG/ML SOLN 1.25 ML VIAL,206160,CDM,636,RC,J9347,HCPCS,310450525,NDC,facility,both,1,ME,,8837.1,6627.82,,,,,,,,,,Gross Charge Type: Pharmacy
TREMELIMUMAB-ACTL 20 MG/ML SOLN 1.25 ML VIAL,206160,CDM,636,RC,C9399,HCPCS,310450525,NDC,facility,both,1,ME,,8837.1,6627.82,,,,,,,,,,Gross Charge Type: Pharmacy
TECLISTAMAB-CQYV 10 MG/ML SOLN,206416,CDM,636,RC,J9380,HCPCS,57894044901,NDC,facility,both,0.5,ME,,104.03,78.02,,,,,,,,,,Gross Charge Type: Pharmacy
TECLISTAMAB-CQYV 153 MG/1.7ML SOLN,206417,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,both,0.5,ME,,85.5,64.12,,,,,,,,,,Gross Charge Type: Pharmacy
TECLISTAMAB-CQYV 90 MG/ML SOLN,206417,CDM,636,RC,J9380,HCPCS,57894045001,NDC,facility,both,0.5,ME,,85.13,63.85,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 100 MG/20ML SOLN 20 ML VIAL,206537,CDM,636,RC,J9063,HCPCS,72903085301,NDC,facility,both,1,ME,,166.45,124.84,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT/MULTIMINERAL ADULT LIQD,206930,CDM,250,RC,81033050150,NDC,,,facility,both,15,ML,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
MOSUNETUZUMAB-AXGB 1 MG/ML SOLN 1 ML VIAL,206944,CDM,636,RC,J9350,HCPCS,50242015901,NDC,facility,both,1,ME,,2130.4,1597.8,,,,,,,,,,Gross Charge Type: Pharmacy
MOSUNETUZUMAB-AXGB 30 MG/30 ML SOLN 30 ML VIAL,206945,CDM,636,RC,J9350,HCPCS,50242014201,NDC,facility,both,1,ME,,1564.66,1173.49,,,,,,,,,,Gross Charge Type: Pharmacy
UBLITUXIMAB-XIIY 25  MG/ML SOLN 6 ML VIAL,206957,CDM,636,RC,J2329,HCPCS,73150015006,NDC,facility,both,1,ME,,169.67,127.26,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % SOLN 15 ML BOTTLE,2070,CDM,250,RC,MHS1ML,HCPCS,60219175008,NDC,facility,both,1,ML,,10.23,7.67,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % SOLN 2 ML BOTTLE,2070,CDM,250,RC,MHS1ML,HCPCS,65081702,NDC,facility,both,1,ML,,40.8,30.6,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % SOLN 2 ML BOTTLE,2070,CDM,250,RC,MHS1ML,HCPCS,60219174802,NDC,facility,both,1,ML,,33.55,25.16,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % SOLN 5 ML BOTTLE,2070,CDM,250,RC,MHS1ML,HCPCS,60219174903,NDC,facility,both,1,ML,,14.67,11,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG/5ML SOLN,207115,CDM,250,RC,MHS1ML,HCPCS,62135052047,NDC,facility,both,1,ML,,3.09,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG SUSR 1 EACH VIAL,20745,CDM,636,RC,J0289,HCPCS,469305130,NDC,facility,both,10,ME,,49.46,37.1,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG SUSR 1 EACH VIAL,20745,CDM,636,RC,J0289,HCPCS,55150036501,NDC,facility,both,10,ME,,121.84,91.38,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG SUSR 1 EACH VIAL,20745,CDM,636,RC,J0289,HCPCS,62756023301,NDC,facility,both,10,ME,,93.33,70,,,,,,,,,,Gross Charge Type: Pharmacy
MOISTURIZING SKIN CREAM CREA,207539,CDM,250,RC,72140000021,NDC,,,facility,both,1,GR,,41.1,30.82,,,,,,,,,,Gross Charge Type: Pharmacy
MOISTURIZING SKIN CREAM CREA,207539,CDM,250,RC,904775127,NDC,,,facility,both,1,GR,,42.95,32.21,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3ML SOSY,207780,CDM,636,RC,J1744,HCPCS,69097066468,NDC,facility,both,1,ME,,152.51,114.38,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3ML SOSY,207780,CDM,636,RC,J1744,HCPCS,63323057486,NDC,facility,both,1,ME,,6634,4975.5,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR,207784,CDM,9003928,NDC,,,,,facility,both,5,EA,,7.29,5.47,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR,207784,CDM,9003928,NDC,,,,,facility,both,5,EA,,26.01,19.5,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR,207784,CDM,9003932,NDC,,,,,facility,both,5,EA,,7.42,5.57,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 40 MG/ML SOLR,207784,CDM,636,RC,J2919,HCPCS,9003932,NDC,facility,both,5,ME,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 40 MG/ML SOLR,207784,CDM,636,RC,J2919,HCPCS,9003928,NDC,facility,both,5,ME,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 40 MG/ML SOLR,207784,CDM,636,RC,J3055,HCPCS,9003928,NDC,facility,both,5,ME,,7.42,5.57,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 40 MG/ML SOLR,207784,CDM,636,RC,J2920,HCPCS,9003928,NDC,facility,both,5,ME,,54.33,40.75,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 40 MG/ML SOLR,207784,CDM,636,RC,J2920,HCPCS,9003932,NDC,facility,both,5,ME,,49.34,37.01,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 40 MG/ML SOLR 1 EACH VIAL,207784,CDM,636,RC,J2920,HCPCS,9003928,NDC,facility,both,5,ME,,59.4,44.55,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR,207785,CDM,9004722,NDC,,,,,facility,both,5,EA,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR,207785,CDM,9004722,NDC,,,,,facility,both,5,EA,,35.9,26.92,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 62.5 MG/ML (2 ML) SOLR,207785,CDM,636,RC,J2919,HCPCS,9004722,NDC,facility,both,5,ME,,3.04,2.28,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 62.5 MG/ML (2 ML) SOLR,207785,CDM,636,RC,J3055,HCPCS,9004722,NDC,facility,both,5,ME,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 62.5 MG/ML (2 ML) SOLR,207785,CDM,636,RC,J2930,HCPCS,9004726,NDC,facility,both,5,ME,,69.45,52.09,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 62.5 MG/ML (2 ML) SOLR,207785,CDM,636,RC,J2930,HCPCS,9004722,NDC,facility,both,5,ME,,68.29,51.22,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 62.5 MG/ML (2 ML) SOLR 1 EACH VIAL,207785,CDM,636,RC,J2930,HCPCS,9004722,NDC,facility,both,5,ME,,49.47,37.1,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 62.5 MG/ML (2 ML) SOLR 1 EACH VIAL,207785,CDM,636,RC,J2919,HCPCS,9004722,NDC,facility,both,5,ME,,2.53,1.9,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 500 MG SOLR 1 EACH VIAL,207786,CDM,636,RC,J2930,HCPCS,9000302,NDC,facility,both,5,ME,,40.9,30.68,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 500 MG SOLR 1 EACH VIAL,207786,CDM,636,RC,J2930,HCPCS,9075801,NDC,facility,both,5,ME,,27.52,20.64,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE NA SUC (PF) 500 MG SOLR 1 EACH VIAL,207786,CDM,636,RC,J2919,HCPCS,9075801,NDC,facility,both,5,ME,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC (PF) 1000 MG SOLR,207787,CDM,636,RC,J2919,HCPCS,9001820,NDC,facility,both,5,ME,,2.71,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC (PF) 1000 MG SOLR,207787,CDM,636,RC,J2930,HCPCS,9001820,NDC,facility,both,5,ME,,24.13,18.1,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC (PF) 1000 MG SOLR,207787,CDM,636,RC,J3055,HCPCS,9001820,NDC,facility,both,5,ME,,0.97,0.72,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC (PF) 1000 MG SOLR 1 EACH VIAL,207787,CDM,636,RC,J3055,HCPCS,9001820,NDC,facility,both,5,ME,,0.97,0.72,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC (PF) 1000 MG SOLR 1 EACH VIAL,207787,CDM,636,RC,J2919,HCPCS,9001820,NDC,facility,both,5,ME,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC (PF) 1000 MG SOLR 1 EACH VIAL,207787,CDM,636,RC,J2930,HCPCS,9001820,NDC,facility,both,5,ME,,23.93,17.95,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH PF 10 UNITS/ML SOLN,207792,CDM,636,RC,J1642,HCPCS,64253022235,NDC,facility,both,10,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH PF 100 UNITS/ML SOLN,207793,CDM,636,RC,J1642,HCPCS,64253033335,NDC,facility,both,10,UN,,0.58,0.44,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH PF 100 UNITS/ML SOLN,207793,CDM,636,RC,J1642,HCPCS,8290306424,NDC,facility,both,10,UN,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH PF 100 UNITS/ML SOLN 5 ML SYRINGE,207793,CDM,636,RC,J1642,HCPCS,64253033335,NDC,facility,both,10,UN,,1.99,1.49,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH PF 100 UNITS/ML SOLN 5 ML SYRINGE,207793,CDM,636,RC,J1642,HCPCS,8290306424,NDC,facility,both,10,UN,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 2 G SOLR,207868,CDM,636,RC,J0690,HCPCS,143913925,NDC,facility,both,500,ME,,13.27,9.95,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 2 G SOLR,207868,CDM,636,RC,J0690,HCPCS,143913901,NDC,facility,both,500,ME,,13.28,9.96,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 3 G SOLR,207869,CDM,636,RC,J0690,HCPCS,143914025,NDC,facility,both,500,ME,,10.31,7.73,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 3 G SOLR,207869,CDM,636,RC,J0690,HCPCS,143914001,NDC,facility,both,500,ME,,10.26,7.69,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 3 G SOLR,207869,CDM,636,RC,143914001,NDC,,,facility,both,500,ME,,61.55,46.16,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 3 G SOLR,207869,CDM,636,RC,143914025,NDC,,,facility,both,500,ME,,61.55,46.16,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 2.8 G SUPP,208765,CDM,250,RC,132019012,NDC,,,facility,both,4,ML,,21.8,16.35,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 2.8 G SUPP,208765,CDM,250,RC,132019012,NDC,,,facility,both,1,ML,,20.45,15.34,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 2.8 G SUPP,208765,CDM,250,RC,132019012,NDC,,,facility,both,0.2,ML,,20.05,15.04,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 2.8 G SUPP,208765,CDM,250,RC,132019012,NDC,,,facility,both,0.5,ML,,20.2,15.15,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 2.8 G SUPP,208765,CDM,250,RC,132019012,NDC,,,facility,both,0.6,ML,,20.25,15.19,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP 4 MG/0.8ML SOLN,208990,CDM,636,RC,J9321,HCPCS,82705000201,NDC,facility,both,0.16,ME,,184.31,138.23,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP 4 MG/0.8ML SOLN 0.8 ML VIAL,208990,CDM,636,RC,J9321,HCPCS,82705000201,NDC,facility,both,0.16,ME,,212.25,159.19,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP 5 MG/ML SOLN,208990,CDM,636,RC,J9321,HCPCS,82705000201,NDC,facility,both,0.16,ME,,187.06,140.3,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP 5 MG/ML SOLN 0.8 ML VIAL,208990,CDM,636,RC,J9321,HCPCS,82705000201,NDC,facility,both,0.16,ME,,180.87,135.65,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP 48 MG/0.8ML SOLN,208991,CDM,636,RC,J9321,HCPCS,82705001001,NDC,facility,both,0.16,ME,,137.04,102.78,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP 60 MG/ML SOLN,208991,CDM,636,RC,J9321,HCPCS,82705001001,NDC,facility,both,0.16,ME,,137.04,102.78,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG TABS,20941,CDM,250,RC,63739026910,NDC,,,facility,both,2,UN,,21.6,16.2,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG TABS,20941,CDM,250,RC,591247260,NDC,,,facility,both,2,UN,,21.48,16.11,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG TABS,20941,CDM,250,RC,63739014310,NDC,,,facility,both,2,UN,,21.62,16.22,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG TABS,20941,CDM,250,RC,63739014310,NDC,,,facility,both,1,UN,,39.15,29.36,,,,,,,,,,Gross Charge Type: Pharmacy
NIRSEVIMAB-ALIP 50 MG/0.5 ML SOSY,210371,CDM,636,RC,90380,HCPCS,49281057500,NDC,facility,both,0.5,ML,,820.05,615.04,,,,,,,,,,Gross Charge Type: Pharmacy
ELRANATAMAB-BCMM 40 MG/ML SOLN,210420,CDM,636,RC,J1323,HCPCS,69449401,NDC,facility,both,1,ME,,460,345,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG CAPS,21096,CDM,250,RC,67877014601,NDC,,,facility,both,1,UN,,5.36,4.02,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG CAPS,21096,CDM,250,RC,67877014601,NDC,,,facility,both,2,UN,,2.8,2.1,,,,,,,,,,Gross Charge Type: Pharmacy
MIRIKIZUMAB-MRKZ 20 MG/ML SOLN 15 ML VIAL,211724,CDM,636,RC,C9399,HCPCS,2757501,NDC,facility,both,1,ME,,78.85,59.14,,,,,,,,,,Gross Charge Type: Pharmacy
MIRIKIZUMAB-MRKZ 20 MG/ML SOLN 15 ML VIAL,211724,CDM,636,RC,C9168,HCPCS,2757501,NDC,facility,both,1,ME,,78.85,59.14,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE 0.5 % SOLN 4 ML PLAS CONT,21203,CDM,250,RC,MHS1ML,HCPCS,65074114,NDC,facility,both,1,ML,,10.84,8.13,,,,,,,,,,Gross Charge Type: Pharmacy
TETRAHYDROZOLINE 0.05 % SOLN 15 ML BOTTLE,21216,CDM,250,RC,MHS1ML,HCPCS,536121794,NDC,facility,both,1,ML,,1.83,1.37,,,,,,,,,,Gross Charge Type: Pharmacy
TETRAHYDROZOLINE 0.05 % SOLN 15 ML BOTTLE,21216,CDM,250,RC,MHS1ML,HCPCS,49348003729,NDC,facility,both,1,ML,,1.8,1.35,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 100 MG/4ML SOLN 4 ML VIAL,212671,CDM,636,RC,J9034,HCPCS,63459034804,NDC,facility,both,1,ME,,51.16,38.37,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN THERAPEUTIC TABS,21340,CDM,250,RC,904053961,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN THERAPEUTIC TABS,21340,CDM,250,RC,904053961,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
THERA TABS,21340,CDM,250,RC,904053961,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
MULTI-VITAMIN TABS,21363,CDM,250,RC,57896053110,NDC,,,facility,both,1,UN,,6.04,4.53,,,,,,,,,,Gross Charge Type: Pharmacy
MULTI-VITAMIN TABS,21363,CDM,250,RC,80681011200,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
MULTI-VITAMIN TABS,21363,CDM,250,RC,57896053110,NDC,,,facility,both,2,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML SOLN,21498,CDM,636,RC,J3411,HCPCS,63323001302,NDC,facility,both,100,ME,,27.75,20.81,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML SOLN,21498,CDM,636,RC,J3411,HCPCS,72603013901,NDC,facility,both,100,ME,,50.8,38.1,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML SOLN,21498,CDM,636,RC,J3411,HCPCS,72603013925,NDC,facility,both,100,ME,,47.59,35.69,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML SOLN,21498,CDM,636,RC,J3411,HCPCS,67457019602,NDC,facility,both,100,ME,,31.78,23.83,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML SOLN 2 ML VIAL,21498,CDM,636,RC,J3411,HCPCS,67457019602,NDC,facility,both,100,ME,,19.93,14.95,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML SOLN 2 ML VIAL,21498,CDM,636,RC,J3411,HCPCS,63323001302,NDC,facility,both,100,ME,,16.72,12.54,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML SOLN 2 ML VIAL,21498,CDM,636,RC,J3411,HCPCS,72603013925,NDC,facility,both,100,ME,,43.77,32.82,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML SOLN 2 ML VIAL,21498,CDM,636,RC,J3411,HCPCS,72603013901,NDC,facility,both,100,ME,,27.42,20.56,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML SOLN 2 ML VIAL,21498,CDM,636,RC,J3411,HCPCS,641622825,NDC,facility,both,100,ME,,27.58,20.68,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES VACCINE SUSR,21562,CDM,636,RC,90675,HCPCS,50632001001,NDC,facility,both,1,ML,,546.7,410.02,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES VACCINE SUSR,21562,CDM,636,RC,90675,HCPCS,50632001301,NDC,facility,both,1,ML,,546.7,410.02,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,6.5,UN,,2.33,1.75,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,3,UN,,3.97,2.97,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,2.5,UN,,3.73,2.8,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,0.5,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,6,UN,,2.62,1.96,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,1.5,UN,,4.9,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,1,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,8,UN,,2.25,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,2,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,4,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID 30 MG TABS,21636,CDM,250,RC,42192032901,NDC,,,facility,both,7,UN,,2.41,1.81,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 75 MG TABS,21691,CDM,250,RC,904629461,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 75 MG TABS,21691,CDM,250,RC,904629461,NDC,,,facility,both,8,UN,,1.34,1,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 75 MG TABS,21691,CDM,250,RC,904629461,NDC,,,facility,both,3,UN,,2.93,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 75 MG TABS,21691,CDM,250,RC,904629461,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 75 MG TABS,21691,CDM,250,RC,904629461,NDC,,,facility,both,4,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 75 MG TABS,21691,CDM,250,RC,904629461,NDC,,,facility,both,2,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
RALOXIFENE 60 MG TABS,21699,CDM,250,RC,16714021302,NDC,,,facility,both,2,UN,,5.5,4.12,,,,,,,,,,Gross Charge Type: Pharmacy
RALOXIFENE 60 MG TABS,21699,CDM,250,RC,16714021302,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
RALOXIFENE 60 MG TABS,21699,CDM,250,RC,93729001,NDC,,,facility,both,1,UN,,15.6,11.7,,,,,,,,,,Gross Charge Type: Pharmacy
TOLNAFTATE 1 % CREA 30 G TUBE,21770,CDM,250,RC,51672202002,NDC,,,facility,both,30,GR,,46,34.5,,,,,,,,,,Gross Charge Type: Pharmacy
FOMEPIZOLE 1 G/ML SOLN 1.5 ML VIAL,21876,CDM,636,RC,J1451,HCPCS,67457021102,NDC,facility,both,15,ME,,23.28,17.46,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 15 MG TABS,21927,CDM,250,RC,67814301,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 15 MG TABS,21927,CDM,250,RC,67000308,NDC,,,facility,both,2,UN,,4.28,3.21,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 15 MG TABS,21927,CDM,250,RC,67000308,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,904686961,NDC,,,facility,both,2,UN,,4.07,3.05,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,904686961,NDC,,,facility,both,1,UN,,6.13,4.59,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,904686961,NDC,,,facility,both,1.5,UN,,3.85,2.89,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,904686961,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,904686961,NDC,,,facility,both,0.75,UN,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,68382080601,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,60687045401,NDC,,,facility,both,1,UN,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,904686961,NDC,,,facility,both,2.5,UN,,2.87,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,904686961,NDC,,,facility,both,4,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG TABS,21940,CDM,250,RC,904686961,NDC,,,facility,both,3,UN,,2.93,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,68382080701,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,60687043211,NDC,,,facility,both,0.666666667,UN,,7.95,5.96,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,60687043211,NDC,,,facility,both,0.5,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,60687043211,NDC,,,facility,both,2,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,60687043211,NDC,,,facility,both,1.6667,UN,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,60687043211,NDC,,,facility,both,3,UN,,3.57,2.67,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,60687043211,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,60687043211,NDC,,,facility,both,3.3333,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,60687043211,NDC,,,facility,both,0.8333,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG TABS,21941,CDM,250,RC,68382080701,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,904686861,NDC,,,facility,both,4,UN,,2.16,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,50111056001,NDC,,,facility,both,4,UN,,1.86,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,904686861,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,904686861,NDC,,,facility,both,5,UN,,1.78,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,60687044301,NDC,,,facility,both,2,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,904686861,NDC,,,facility,both,2,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,904686861,NDC,,,facility,both,1.5,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,68382080501,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,904686861,NDC,,,facility,both,2.5,UN,,2.62,1.96,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,68382080501,NDC,,,facility,both,1.5,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,60687044301,NDC,,,facility,both,1,UN,,6.63,4.98,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,60687044301,NDC,,,facility,both,3,UN,,2.8,2.1,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,904686861,NDC,,,facility,both,3,UN,,2.73,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,50111056001,NDC,,,facility,both,1.5,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,50111056001,NDC,,,facility,both,2,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,68382080501,NDC,,,facility,both,1,UN,,6.34,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,50111056001,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,68382080501,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,50111056001,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,60687044301,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,904686861,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,50111056001,NDC,,,facility,both,3,UN,,2.37,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,60687044301,NDC,,,facility,both,4,UN,,2.19,1.64,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,60687044301,NDC,,,facility,both,1.5,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,60687044301,NDC,,,facility,both,6,UN,,1.55,1.16,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,68382080501,NDC,,,facility,both,3,UN,,2.43,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS,21942,CDM,250,RC,904686861,NDC,,,facility,both,6,UN,,1.53,1.15,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 50 MG TABS 1 EACH BLISTER,21942,CDM,250,RC,60687044301,NDC,,,facility,both,1.5,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 0.1 % CREA,22077,CDM,250,RC,MHS1GM,HCPCS,16714098601,NDC,facility,both,1,GM,,2.63,1.97,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 0.1 % CREA 15 G TUBE,22077,CDM,250,RC,MHS1GM,HCPCS,168000415,NDC,facility,both,1,GM,,2.81,2.1,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 0.1 % CREA 80 G TUBE,22077,CDM,250,RC,MHS1GM,HCPCS,168000480,NDC,facility,both,1,GM,,0.62,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 0.5 % CREA 15 G TUBE,22078,CDM,250,RC,45802006535,NDC,,,facility,both,15,GR,,48.45,36.34,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 0.1 % LOTN 60 ML BOTTLE,22080,CDM,250,RC,60432056161,NDC,,,facility,both,60,ML,,61.9,46.42,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 0.1 % OINT 15 G TUBE,22082,CDM,250,RC,MHS1GM,HCPCS,45802005535,NDC,facility,both,1,GM,,2.71,2.03,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 0.1 % OINT 15 G TUBE,22082,CDM,250,RC,MHS1GM,HCPCS,168000615,NDC,facility,both,1,GM,,3.01,2.26,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 0.1 % OINT 80 G TUBE,22082,CDM,250,RC,MHS1GM,HCPCS,45802005536,NDC,facility,both,1,GM,,2.54,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 0.5 % OINT 15 G TUBE,22083,CDM,250,RC,MHS1GM,HCPCS,45802004935,NDC,facility,both,1,GM,,3.11,2.33,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 40 MG/ML SUSP,22084,CDM,636,RC,J3301,HCPCS,3029328,NDC,facility,both,10,ME,,16.95,12.72,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 40 MG/ML SUSP,22084,CDM,636,RC,J3301,HCPCS,70121104905,NDC,facility,both,10,ME,,12.73,9.55,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 40 MG/ML SUSP,22084,CDM,636,RC,J3301,HCPCS,3029305,NDC,facility,both,10,ME,,15.46,11.6,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 40 MG/ML SUSP,22084,CDM,636,RC,J3301,HCPCS,70121104902,NDC,facility,both,10,ME,,2.46,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 40 MG/ML SUSP,22084,CDM,636,RC,J3301,HCPCS,70121116901,NDC,facility,both,10,ME,,7.51,5.63,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,22084,CDM,16714013025,NDC,,,,,facility,both,10,ML,,18.45,13.84,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,22084,CDM,70121104905,NDC,,,,,facility,both,10,ML,,12.58,9.43,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,22084,CDM,70121165105,NDC,,,,,facility,both,10,ML,,12.66,9.5,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,22084,CDM,70121104902,NDC,,,,,facility,both,10,ML,,5.38,4.04,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,22084,CDM,3029305,NDC,,,,,facility,both,10,ML,,15.09,11.32,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,22084,CDM,70121104901,NDC,,,,,facility,both,10,ML,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,22084,CDM,70121157301,NDC,,,,,facility,both,10,ML,,12.64,9.48,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 300 MG/5ML NEBU,22094,CDM,250,RC,MHS5ML,HCPCS,65162091446,NDC,facility,both,5,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5-25 MG TABS,22115,CDM,250,RC,68084075025,NDC,,,facility,both,2,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5-25 MG TABS,22115,CDM,250,RC,68084075025,NDC,,,facility,both,0.5,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5-25 MG TABS,22115,CDM,250,RC,60505265601,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5-25 MG TABS,22115,CDM,250,RC,68084075025,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 75-50 MG TABS,22117,CDM,250,RC,60505265701,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 75-50 MG TABS,22117,CDM,250,RC,60505265701,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAZOLAM 0.25 MG TABS,22129,CDM,250,RC,59762371809,NDC,,,facility,both,1,UN,,11.15,8.36,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % CREA 30 G TUBE,22141,CDM,250,RC,MHS1GM,HCPCS,68462056435,NDC,facility,both,1,GM,,17.1,12.83,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % SOLN 5 ML BOTTLE,22161,CDM,250,RC,MHS1ML,HCPCS,60505036301,NDC,facility,both,1,ML,,23.95,17.96,,,,,,,,,,Gross Charge Type: Pharmacy
TRIHEXYPHENIDYL 2 MG TABS,22197,CDM,250,RC,70954021210,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
TRIHEXYPHENIDYL 5 MG TABS,22198,CDM,250,RC,70954021110,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
TROPICAMIDE 0.5 % SOLN 15 ML BOTTLE,22401,CDM,250,RC,MHS1ML,HCPCS,61314035401,NDC,facility,both,1,ML,,4.04,3.03,,,,,,,,,,Gross Charge Type: Pharmacy
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,22431,CDM,49281075221,NDC,,,,,facility,both,5,ML,,44.02,33.01,,,,,,,,,,Gross Charge Type: Pharmacy
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,22431,CDM,49281075278,NDC,,,,,facility,both,5,ML,,73.9,55.42,,,,,,,,,,Gross Charge Type: Pharmacy
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,22431,CDM,49281075221,NDC,,,,,facility,both,5,ML,,44.41,33.31,,,,,,,,,,Gross Charge Type: Pharmacy
TUBERCULIN PPD 5 UNITS/0.1 ML SOLN,22431,CDM,250,RC,MHS5UNITS,HCPCS,42023010401,NDC,facility,both,5,UN,,70.6,52.95,,,,,,,,,,Gross Charge Type: Pharmacy
TUBERCULIN PPD 5 UNITS/0.1 ML SOLN,22431,CDM,250,RC,J3490,HCPCS,49281075221,NDC,facility,both,5,UN,,62.62,46.96,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT TABS,22975,CDM,250,RC,77333043050,NDC,,,facility,both,3,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT TABS,22975,CDM,250,RC,77333043050,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT TABS,22975,CDM,250,RC,904522452,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT TABS,22975,CDM,250,RC,904522452,NDC,,,facility,both,3,UN,,2.43,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT TABS,22975,CDM,250,RC,77333043025,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 15 MG/ML SOLN,22987,CDM,636,RC,J1885,HCPCS,62332059901,NDC,facility,both,15,ME,,36.23,27.18,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 15 MG/ML SOLN,22987,CDM,636,RC,J1885,HCPCS,72572035401,NDC,facility,both,15,ME,,27.05,20.29,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 15 MG/ML SOLN,22987,CDM,636,RC,J1885,HCPCS,62332059925,NDC,facility,both,15,ME,,36.89,27.67,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 15 MG/ML SOLN,22987,CDM,636,RC,J1885,HCPCS,409379301,NDC,facility,both,15,ME,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 15 MG/ML SOLN,22987,CDM,636,RC,J1885,HCPCS,63323016101,NDC,facility,both,15,ME,,28.64,21.48,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 15 MG/ML SOLN,22987,CDM,636,RC,J1885,HCPCS,63323016100,NDC,facility,both,15,ME,,28.96,21.72,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 15 MG/ML SOLN,22987,CDM,636,RC,J1885,HCPCS,338006910,NDC,facility,both,15,ME,,31.42,23.57,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN,22987,CDM,63323016100,NDC,,,,,facility,both,15,ML,,11.92,8.94,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN,22987,CDM,63323016101,NDC,,,,,facility,both,15,ML,,26.41,19.8,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 30 MG/ML SOLN,22992,CDM,636,RC,J1885,HCPCS,338007225,NDC,facility,both,15,ME,,24.71,18.53,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 30 MG/ML SOLN,22992,CDM,636,RC,J1885,HCPCS,62332060001,NDC,facility,both,15,ME,,28.37,21.28,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 30 MG/ML SOLN,22992,CDM,636,RC,J1885,HCPCS,63323016201,NDC,facility,both,15,ME,,20.06,15.04,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 30 MG/ML SOLN,22992,CDM,636,RC,J1885,HCPCS,72266011801,NDC,facility,both,15,ME,,23.16,17.37,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 30 MG/ML SOLN,22992,CDM,636,RC,J1885,HCPCS,72572035501,NDC,facility,both,15,ME,,23.82,17.86,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 30 MG/ML SOLN,22992,CDM,636,RC,J1885,HCPCS,409379501,NDC,facility,both,15,ME,,41.49,31.12,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,22992,CDM,63323016201,NDC,,,,,facility,both,15,ML,,20.16,15.12,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,22992,CDM,72266011801,NDC,,,,,facility,both,15,ML,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,22992,CDM,63323016200,NDC,,,,,facility,both,15,ML,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG TABS,23049,CDM,250,RC,904680861,NDC,,,facility,both,0.5,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG TABS,23049,CDM,250,RC,904680861,NDC,,,facility,both,1,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 5 MG CHEW,23051,CDM,250,RC,57237021330,NDC,,,facility,both,2,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 5 MG CHEW,23051,CDM,250,RC,50268057415,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 5 MG CHEW,23051,CDM,250,RC,57237021330,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG CAPS,23071,CDM,250,RC,69452015020,NDC,,,facility,both,2,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG CAPS,23071,CDM,250,RC,69452015020,NDC,,,facility,both,1,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN SOLR 1 EACH VIAL,23108,CDM,636,RC,J3370,HCPCS,409433211,NDC,facility,both,500,ME,,41.8,31.35,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN SOLR 1 EACH VIAL,23108,CDM,636,RC,J3371,HCPCS,67457033950,NDC,facility,both,500,ME,,40.12,30.09,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN SOLR 1 EACH VIAL,23108,CDM,636,RC,J3370,HCPCS,67457033950,NDC,facility,both,500,ME,,43.51,32.64,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML SOLN,23274,CDM,250,RC,MHS1ML,HCPCS,409114402,NDC,facility,both,1,ML,,19.39,14.54,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML SOLN,23274,CDM,250,RC,MHS1ML,HCPCS,409114405,NDC,facility,both,1,ML,,36.02,27.02,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML SOLN,23274,CDM,250,RC,MHS1ML,HCPCS,72485010801,NDC,facility,both,1,ML,,39.4,29.55,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML SOLN,23274,CDM,250,RC,MHS1ML,HCPCS,72485010825,NDC,facility,both,1,ML,,37.68,28.26,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML SOLN 2 ML VIAL,23274,CDM,250,RC,MHS1ML,HCPCS,409114405,NDC,facility,both,1,ML,,36.02,27.02,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML SOLN 2 ML VIAL,23274,CDM,250,RC,MHS1ML,HCPCS,72485010825,NDC,facility,both,1,ML,,37.68,28.26,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG TABS,23275,CDM,250,RC,23155048601,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 40 MG TABS,23276,CDM,250,RC,591040401,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 40 MG TABS,23276,CDM,250,RC,591040401,NDC,,,facility,both,2,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 80 MG TABS,23277,CDM,250,RC,23155002601,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 80 MG TABS,23277,CDM,250,RC,904292061,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML SUSP,23286,CDM,250,RC,MHS1ML,HCPCS,65862049647,NDC,facility,both,1,ML,,0.34,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
VINBLASTINE 1 MG/ML SOLN 10 ML VIAL,23421,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,both,1,ME,,18.45,13.83,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 1 MG/ML SOLN 1 ML VIAL,23426,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,both,1,ME,,17.46,13.1,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 1 MG/ML SOLN 2 ML VIAL,23426,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,both,1,ME,,22.18,16.63,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE (VITAMIN B1) 50 MG TABS,23569,CDM,250,RC,80681009700,NDC,,,facility,both,2,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE (VITAMIN B1) 50 MG TABS,23569,CDM,250,RC,80681009700,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,50268085415,NDC,,,facility,both,4,UN,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,50268085415,NDC,,,facility,both,6,UN,,1.6,1.2,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,50268085415,NDC,,,facility,both,1,UN,,6.84,5.13,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,50268085415,NDC,,,facility,both,10,UN,,1.09,0.82,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,50268085415,NDC,,,facility,both,2,UN,,3.95,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,77333093710,NDC,,,facility,both,5,UN,,1.83,1.37,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,77333093710,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,77333093710,NDC,,,facility,both,3,UN,,2.83,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,50268085415,NDC,,,facility,both,5,UN,,1.86,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,50268085415,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,77333093710,NDC,,,facility,both,1,UN,,6.59,4.94,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,77333093710,NDC,,,facility,both,2,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN (VITAMIN B12) 500 MCG TABS,23584,CDM,250,RC,77333093710,NDC,,,facility,both,4,UN,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE (VITAMIN B6) 100 MG TABS,23600,CDM,250,RC,80681002500,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE (VITAMIN B6) 100 MG TABS,23600,CDM,250,RC,50268085915,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE (VITAMIN B6) 50 MG TABS,23604,CDM,250,RC,50268085815,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE (VITAMIN B6) 50 MG TABS,23604,CDM,250,RC,50268085815,NDC,,,facility,both,2,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE (VITAMIN B6) 50 MG TABS,23604,CDM,250,RC,50268085815,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID (VITAMIN C) 250 MG TABS,23638,CDM,250,RC,50268086015,NDC,,,facility,both,2,UN,,4.15,3.11,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID (VITAMIN C) 250 MG TABS,23638,CDM,250,RC,50268086015,NDC,,,facility,both,4,UN,,2.31,1.73,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID (VITAMIN C) 250 MG TABS,23638,CDM,250,RC,50268086015,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID (VITAMIN C) 250 MG TABS,23638,CDM,250,RC,50268086015,NDC,,,facility,both,3,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID (VITAMIN C) 250 MG TABS,23638,CDM,250,RC,20555000100,NDC,,,facility,both,4,UN,,1.6,1.2,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID (VITAMIN C) 250 MG TABS,23638,CDM,250,RC,20555000100,NDC,,,facility,both,1,UN,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID (VITAMIN C) 250 MG TABS,23638,CDM,250,RC,50268086015,NDC,,,facility,both,1,UN,,7.11,5.33,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID (VITAMIN C) 250 MG TABS,23638,CDM,250,RC,20555000100,NDC,,,facility,both,2,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 250 MG TABS,23649,CDM,250,RC,591299801,NDC,,,facility,both,3,UN,,4.37,3.27,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 250 MG TABS,23649,CDM,250,RC,591299801,NDC,,,facility,both,4,UN,,3.69,2.77,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 250 MG TABS,23649,CDM,250,RC,591299801,NDC,,,facility,both,2,UN,,5.68,4.26,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 250 MG TABS,23649,CDM,250,RC,591299801,NDC,,,facility,both,1,UN,,9.55,7.16,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML SOLN,23738,CDM,636,RC,J3430,HCPCS,409915801,NDC,facility,both,1,ME,,14.32,10.74,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML SOLN 1 ML AMPULE,23738,CDM,636,RC,J3430,HCPCS,43598040516,NDC,facility,both,1,ME,,10.83,8.12,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML SOLN 1 ML AMPULE,23738,CDM,636,RC,J3430,HCPCS,409915801,NDC,facility,both,1,ME,,11.54,8.66,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML SOLN 1 ML AMPULE,23738,CDM,636,RC,J3430,HCPCS,409915825,NDC,facility,both,1,ME,,10.59,7.95,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/GM OINT,2374,CDM,250,RC,MHS1GM,HCPCS,45802006070,NDC,facility,both,1,GM,,23.79,17.84,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/GM OINT 14 G TUBE,2374,CDM,250,RC,MHS1GM,HCPCS,45802006001,NDC,facility,both,1,GM,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/GM OINT 28.4 G TUBE,2374,CDM,250,RC,MHS1GM,HCPCS,713028031,NDC,facility,both,1,GM,,1.4,1.05,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN-POLYMYXIN 500-10000 UNIT/GM OINT 3.5 G TUBE,2383,CDM,250,RC,24208055555,NDC,,,facility,both,3.5,GR,,38.05,28.54,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2 MG TABS,23834,CDM,250,RC,832121201,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2 MG TABS,23834,CDM,250,RC,832121201,NDC,,,facility,both,2,UN,,3.79,2.84,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2 MG TABS,23834,CDM,250,RC,832121201,NDC,,,facility,both,3,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2 MG TABS,23834,CDM,250,RC,832121201,NDC,,,facility,both,4,UN,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2 MG TABS,23834,CDM,250,RC,832121201,NDC,,,facility,both,1.25,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2 MG TABS,23834,CDM,250,RC,832121201,NDC,,,facility,both,1,UN,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2.5 MG TABS,23835,CDM,250,RC,832121301,NDC,,,facility,both,1,UN,,5.66,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2.5 MG TABS,23835,CDM,250,RC,832121301,NDC,,,facility,both,2,UN,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2.5 MG TABS,23835,CDM,250,RC,832121301,NDC,,,facility,both,4,UN,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2.5 MG TABS,23835,CDM,250,RC,832121301,NDC,,,facility,both,1.2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2.5 MG TABS,23835,CDM,250,RC,832121301,NDC,,,facility,both,3,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2.5 MG TABS,23835,CDM,250,RC,832121301,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 2.5 MG TABS,23835,CDM,250,RC,832121301,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 5 MG TABS,23836,CDM,250,RC,832121601,NDC,,,facility,both,1.1,UN,,0.5,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 5 MG TABS,23836,CDM,250,RC,832121601,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 5 MG TABS,23836,CDM,250,RC,832121601,NDC,,,facility,both,1.2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 5 MG TABS,23836,CDM,250,RC,832121601,NDC,,,facility,both,1,UN,,5.48,4.11,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 5 MG TABS,23836,CDM,250,RC,832121601,NDC,,,facility,both,2,UN,,3.71,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 5 MG TABS,23836,CDM,250,RC,832121601,NDC,,,facility,both,0.8,UN,,0.75,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 5 MG TABS,23836,CDM,250,RC,832121601,NDC,,,facility,both,3,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN SODIUM 7.5 MG TABS,23837,CDM,250,RC,832121801,NDC,,,facility,both,1,UN,,5.39,4.04,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN SODIUM 7.5 MG TABS,23837,CDM,250,RC,832121801,NDC,,,facility,both,2,UN,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,60687058121,NDC,,,facility,both,3,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,60687058121,NDC,,,facility,both,1.25,UN,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,60687058121,NDC,,,facility,both,2,UN,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,68462033290,NDC,,,facility,both,1.5,UN,,3.2,2.4,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,68462033290,NDC,,,facility,both,4,UN,,1.74,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,60687058121,NDC,,,facility,both,4.5,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,60687058121,NDC,,,facility,both,4,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,68462033290,NDC,,,facility,both,3,UN,,2.25,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,68462033290,NDC,,,facility,both,0.5,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,68462033290,NDC,,,facility,both,1,UN,,5.97,4.48,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,68462033290,NDC,,,facility,both,2,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,60687058121,NDC,,,facility,both,0.5,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,60687058121,NDC,,,facility,both,1,UN,,9,6.75,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG TABS,23852,CDM,250,RC,60687058121,NDC,,,facility,both,1.5,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,63739047910,NDC,,,facility,both,1.5,UN,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,904647561,NDC,,,facility,both,2,UN,,4.66,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,16714007104,NDC,,,facility,both,1,UN,,6.49,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,63739047910,NDC,,,facility,both,1,UN,,8.48,6.36,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,16714007104,NDC,,,facility,both,0.25,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,16714007104,NDC,,,facility,both,2,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,904647561,NDC,,,facility,both,4,UN,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,16714007104,NDC,,,facility,both,1.5,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,63739047910,NDC,,,facility,both,3,UN,,3.47,2.6,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,16714007104,NDC,,,facility,both,4,UN,,2.1,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,63739047910,NDC,,,facility,both,0.25,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,63739047910,NDC,,,facility,both,0.5,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,603240621,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,63739047910,NDC,,,facility,both,4,UN,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,31722099801,NDC,,,facility,both,3,UN,,2.38,1.79,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,63739047910,NDC,,,facility,both,2,UN,,4.75,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,31722099801,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,31722099801,NDC,,,facility,both,2,UN,,3.34,2.5,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,904647561,NDC,,,facility,both,1.5,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,31722099801,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,904647561,NDC,,,facility,both,3,UN,,3.47,2.6,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,16714007104,NDC,,,facility,both,3,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,16714007104,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,904647561,NDC,,,facility,both,0.5,UN,,7.19,5.39,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,31722099801,NDC,,,facility,both,1.5,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,603240621,NDC,,,facility,both,1.5,UN,,2.58,1.94,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG TABS,2388,CDM,250,RC,904647561,NDC,,,facility,both,1,UN,,8.37,6.28,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG TABS,24149,CDM,250,RC,33342009809,NDC,,,facility,both,0.5,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG TABS,24149,CDM,250,RC,33342009809,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.15,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,15,ML,,44.4,33.3,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,22,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.29,ML,,48.15,36.11,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.23,ML,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,23,ML,,36.67,27.5,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.22,ML,,47.95,35.96,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,5,ML,,61.55,46.16,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.26,ML,,48.1,36.08,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.14,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,14,ML,,43.05,32.29,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,4,ML,,58.8,44.1,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.17,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.21,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.18,ML,,47.85,35.89,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,1.02,ML,,50.35,37.76,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,18,ML,,48.5,36.38,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,8,ML,,69.75,52.31,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.09,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.16,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,16,ML,,45.78,34.33,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,6,ML,,64.25,48.19,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.19,ML,,47.85,35.89,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,19,ML,,49.82,37.37,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.28,ML,,48.15,36.11,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.11,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.27,ML,,48.1,36.08,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,12,ML,,40.32,30.24,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.12,ML,,47.65,35.74,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,24,ML,,37.53,28.15,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.24,ML,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.31,ML,,48.25,36.19,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,10,ML,,75.2,56.4,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.1,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,1,ML,,50.3,37.72,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.25,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.3,ML,,48.2,36.15,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,3,ML,,56,42,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,7,ML,,67,50.25,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,13,ML,,41.68,31.26,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.13,ML,,47.65,35.74,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,20,ML,,51.12,38.34,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,2,ML,,53.15,39.86,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL,24160,CDM,250,RC,409409001,NDC,,,facility,both,0.2,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % OINT 28 G TUBE,24175,CDM,250,RC,MHS1GM,HCPCS,51824003203,NDC,facility,both,1,GM,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % OINT 30 G TUBE,24175,CDM,250,RC,MHS1GM,HCPCS,536131628,NDC,facility,both,1,GM,,1.34,1.01,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC SULFATE 220 (50 ZN) MG CAPS,24188,CDM,250,RC,77333098310,NDC,,,facility,both,1,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSAMINE 500 MG CAPS,24242,CDM,250,RC,50268037515,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSAMINE 500 MG CAPS,24242,CDM,250,RC,43292055857,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSAMINE 500 MG CAPS,24242,CDM,250,RC,43292055857,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
ACEBUTOLOL 200 MG CAPS,24325,CDM,250,RC,53746066901,NDC,,,facility,both,2,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
ACEBUTOLOL 200 MG CAPS,24325,CDM,250,RC,50268005015,NDC,,,facility,both,1,UN,,10.4,7.8,,,,,,,,,,Gross Charge Type: Pharmacy
ACEBUTOLOL 200 MG CAPS,24325,CDM,250,RC,50268005015,NDC,,,facility,both,2,UN,,6.48,4.86,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5ML SUSP,24340,CDM,250,RC,MHS1ML,HCPCS,68094023161,NDC,facility,both,1,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 1 MG/ML SOLR 4 ML VIAL,2440,CDM,636,RC,J9351,HCPCS,409030201,NDC,facility,both,0.1,ME,,2.28,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",24405,CDM,250,RC,338065604,NDC,,,facility,both,50,ML,,1.1,0.82,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETIC ACID 0.25 % SOLN 1,000 ML PLAS CONT",24405,CDM,250,RC,338065604,NDC,,,facility,both,250,ML,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 5 % OINT 15 G TUBE,24416,CDM,250,RC,MHS1GM,HCPCS,378870006,NDC,facility,both,1,GM,,10.29,7.71,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 5 % OINT 15 G TUBE,24416,CDM,250,RC,MHS1GM,HCPCS,51672136001,NDC,facility,both,1,GM,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG CAPS,24418,CDM,250,RC,904578961,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG CAPS,24418,CDM,250,RC,904578961,NDC,,,facility,both,4,UN,,2.16,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG CAPS,24418,CDM,250,RC,904578961,NDC,,,facility,both,2,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 400 MG TABS,24421,CDM,250,RC,904579061,NDC,,,facility,both,2,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 400 MG TABS,24421,CDM,250,RC,904579061,NDC,,,facility,both,0.5,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 400 MG TABS,24421,CDM,250,RC,904579061,NDC,,,facility,both,1,UN,,8.04,6.03,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 400 MG TABS,24421,CDM,250,RC,50268006115,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 400 MG TABS,24421,CDM,250,RC,50268006115,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 400 MG TABS,24421,CDM,250,RC,50268006115,NDC,,,facility,both,0.5,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 400 MG TABS,24421,CDM,250,RC,31722077701,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG TABS,24422,CDM,250,RC,68084010901,NDC,,,facility,both,0.5,UN,,8.25,6.19,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG TABS,24422,CDM,250,RC,50268006215,NDC,,,facility,both,0.5,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG TABS,24422,CDM,250,RC,68084010901,NDC,,,facility,both,1,UN,,9.2,6.9,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG TABS,24422,CDM,250,RC,50268006215,NDC,,,facility,both,1,UN,,9.55,7.16,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 25% (HUMAN) 0.25 GM/ML SOLN,24443,CDM,636,RC,P9047,HCPCS,944049303,NDC,facility,both,50,ML,,86.88,65.16,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 25% (HUMAN) 0.25 GM/ML SOLN,24443,CDM,636,RC,P9047,HCPCS,44206025105,NDC,facility,both,50,ML,,118.68,89.01,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 25% (HUMAN) 0.25 GM/ML SOLN,24443,CDM,636,RC,P9047,HCPCS,944049302,NDC,facility,both,50,ML,,104.03,78.02,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 25% (HUMAN) 0.25 GM/ML SOLN,24443,CDM,636,RC,P9047,HCPCS,44206025110,NDC,facility,both,50,ML,,100.43,75.33,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 25% (HUMAN) 0.25 GM/ML SOLN,24443,CDM,636,RC,P9047,HCPCS,68516521601,NDC,facility,both,50,ML,,160.04,120.03,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 25% (HUMAN) 0.25 GM/ML SOLN,24443,CDM,636,RC,P9047,HCPCS,944049301,NDC,facility,both,50,ML,,132.11,99.08,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 5% (HUMAN) 50 MG/ML SOLN,24444,CDM,636,RC,P9045,HCPCS,44206031050,NDC,facility,both,250,ML,,102.39,76.79,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 5% (HUMAN) 50 MG/ML SOLN,24444,CDM,636,RC,P9045,HCPCS,68516521404,NDC,facility,both,250,ML,,129.2,96.9,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 5% (HUMAN) 50 MG/ML SOLN,24444,CDM,636,RC,P9045,HCPCS,44206031025,NDC,facility,both,250,ML,,109.95,82.46,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 5% (HUMAN) 50 MG/ML SOLN,24444,CDM,636,RC,P9045,HCPCS,68982062303,NDC,facility,both,250,ML,,129.2,96.9,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUMIN 5% (HUMAN) 50 MG/ML SOLN,24444,CDM,636,RC,P9045,HCPCS,944049505,NDC,facility,both,250,ML,,186.8,140.1,,,,,,,,,,Gross Charge Type: Pharmacy
ALPROSTADIL 500 MCG/ML SOLN 1 ML AMPULE,24491,CDM,636,RC,J0270,HCPCS,9316906,NDC,facility,both,0.2,ML,,1.41,1.06,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML SOLR,24494,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,both,1,ME,,209.83,157.37,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML SOLR 1 EACH VIAL,24494,CDM,636,RC,J2997,HCPCS,50242008527,NDC,facility,both,1,ME,,209.83,157.38,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE SOLR,24495,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,both,1,ME,,209.83,157.37,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE SOLR 1 EACH VIAL,24495,CDM,636,RC,J2997,HCPCS,50242004413,NDC,facility,both,1,ME,,207.1,155.33,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM & MAGNESIUM HYDROXIDE-SIMETHICONE 200-200-20 MG/5ML SUSP,24509,CDM,250,RC,MHS1ML,HCPCS,63739015910,NDC,facility,both,1,ML,,0.31,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM & MAGNESIUM HYDROXIDE-SIMETHICONE 200-200-20 MG/5ML SUSP,24509,CDM,250,RC,MHS1ML,HCPCS,904732573,NDC,facility,both,1,ML,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM & MAGNESIUM HYDROXIDE-SIMETHICONE 200-200-20 MG/5ML SUSP,24509,CDM,250,RC,MHS1ML,HCPCS,121176130,NDC,facility,both,1,ML,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM & MAGNESIUM HYDROXIDE-SIMETHICONE 200-200-20 MG/5ML SUSP 30 ML CUP,24509,CDM,250,RC,MHS1ML,HCPCS,121176130,NDC,facility,both,1,ML,,0.34,0.25,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 50 MG CAPS,24526,CDM,250,RC,904561646,NDC,,,facility,both,2,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 50 MG CAPS,24526,CDM,250,RC,904561646,NDC,,,facility,both,3,UN,,2.93,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 50 MG CAPS,24526,CDM,250,RC,904561646,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 50 MG CAPS,24526,CDM,250,RC,904561646,NDC,,,facility,both,4,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
BRINZOLAMIDE 1 % SUSP,24598,CDM,250,RC,MHS1ML,HCPCS,591212779,NDC,facility,both,1,ML,,31.8,23.85,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG/5ML SUSP,24605,CDM,250,RC,60505040205,NDC,,,facility,both,5,ML,,21.65,16.24,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG/5ML SUSP,24605,CDM,250,RC,60505040205,NDC,,,facility,both,20,ML,,58.45,43.84,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG/5ML SUSP,24605,CDM,250,RC,60505040205,NDC,,,facility,both,10,ML,,34.28,25.71,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG/5ML SUSP,24605,CDM,250,RC,60505040205,NDC,,,facility,both,30,ML,,90.95,68.21,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 500 MG TABS,24663,CDM,250,RC,62559022530,NDC,,,facility,both,1,UN,,19.2,14.4,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 500 MG TABS,24663,CDM,250,RC,62559022530,NDC,,,facility,both,8,UN,,10.62,7.96,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 500 MG TABS,24663,CDM,250,RC,62559022530,NDC,,,facility,both,2,UN,,14.55,10.91,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2-0.5 % SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,82584060510,NDC,facility,both,1,ML,,34.92,26.19,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2-0.5 % SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,65862094601,NDC,facility,both,1,ML,,5.83,4.37,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2-0.5 % SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,24208048610,NDC,facility,both,1,ML,,10.53,7.9,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2-0.5 % SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,42571014726,NDC,facility,both,1,ML,,5.07,3.8,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2-0.5 % SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,17478060510,NDC,facility,both,1,ML,,33.02,24.77,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2-0.5 % SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,71921022610,NDC,facility,both,1,ML,,5.31,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 22.3-6.8 MG/ML SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,24208048610,NDC,facility,both,1,ML,,10.53,7.9,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 22.3-6.8 MG/ML SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,17478060510,NDC,facility,both,1,ML,,33.02,24.77,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 22.3-6.8 MG/ML SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,42571014726,NDC,facility,both,1,ML,,5.07,3.8,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 22.3-6.8 MG/ML SOLN 10 ML BOTTLE,24665,CDM,250,RC,MHS1ML,HCPCS,82584060510,NDC,facility,both,1,ML,,34.92,26.19,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,904699361,NDC,,,facility,both,2,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,51672402504,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,60687043701,NDC,,,facility,both,1,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,29300035916,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,904699361,NDC,,,facility,both,0.5,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,245014701,NDC,,,facility,both,0.25,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,904699361,NDC,,,facility,both,1,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,245014701,NDC,,,facility,both,0.5,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,245014701,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,245014701,NDC,,,facility,both,1,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,72888003960,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG TABS,24680,CDM,250,RC,51672402504,NDC,,,facility,both,2,UN,,4.9,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG TABS,24684,CDM,250,RC,904637161,NDC,,,facility,both,0.5,UN,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG TABS,24684,CDM,250,RC,904637161,NDC,,,facility,both,0.75,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG TABS,24684,CDM,250,RC,904637161,NDC,,,facility,both,1,UN,,6.44,4.83,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 2.5 MG TABS,24685,CDM,250,RC,904636961,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 2.5 MG TABS,24685,CDM,250,RC,904636961,NDC,,,facility,both,4,UN,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 2.5 MG TABS,24685,CDM,250,RC,904636961,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 2.5 MG TABS,24685,CDM,250,RC,904636961,NDC,,,facility,both,3,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 2.5 MG TABS,24685,CDM,250,RC,904636961,NDC,,,facility,both,2,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 5 MG TABS,24686,CDM,250,RC,904637061,NDC,,,facility,both,1.5,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 5 MG TABS,24686,CDM,250,RC,60687048801,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 5 MG TABS,24686,CDM,250,RC,904637061,NDC,,,facility,both,1,UN,,6.49,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 5 MG TABS,24686,CDM,250,RC,904637061,NDC,,,facility,both,2,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 5 MG TABS,24686,CDM,250,RC,904637061,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 250-62.5 MG/5ML SUSR,24721,CDM,250,RC,MHS1ML,HCPCS,60432006575,NDC,facility,both,1,ML,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TABS,24730,CDM,250,RC,16714095001,NDC,,,facility,both,1.5,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TABS,24730,CDM,250,RC,16714095001,NDC,,,facility,both,3,UN,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TABS,24730,CDM,250,RC,42806034101,NDC,,,facility,both,1,UN,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TABS,24730,CDM,250,RC,16714095001,NDC,,,facility,both,0.5,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TABS,24730,CDM,250,RC,42806034101,NDC,,,facility,both,0.5,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TABS,24730,CDM,250,RC,16714095001,NDC,,,facility,both,1,UN,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TABS,24730,CDM,250,RC,42806034101,NDC,,,facility,both,3,UN,,2.47,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TABS,24730,CDM,250,RC,16714095001,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 20 MG TABS,24731,CDM,250,RC,42806034401,NDC,,,facility,both,1,UN,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 20 MG TABS,24731,CDM,250,RC,555097302,NDC,,,facility,both,1.5,UN,,3.92,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 20 MG TABS,24731,CDM,250,RC,555097302,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM SOLR 1 EACH VIAL,24747,CDM,636,RC,J0295,HCPCS,49001383,NDC,facility,both,1,EA,,43.85,32.89,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM SOLR 1 EACH VIAL,24747,CDM,636,RC,J0295,HCPCS,641611610,NDC,facility,both,1,EA,,51.45,38.59,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM SOLR 1 EACH VIAL,24747,CDM,636,RC,J0295,HCPCS,55150011620,NDC,facility,both,1,EA,,44.45,33.34,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM SOLR 1 EACH VIAL,24748,CDM,636,RC,J0295,HCPCS,641611710,NDC,facility,both,1.5,GM,,33.52,25.14,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM SOLR 1 EACH VIAL,24748,CDM,636,RC,J0295,HCPCS,49001483,NDC,facility,both,1.5,GM,,31.35,23.51,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM SOLR 1 EACH VIAL,24748,CDM,636,RC,J0295,HCPCS,25021014330,NDC,facility,both,1.5,GM,,36.18,27.13,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM SOLR 1 EACH VIAL,24748,CDM,636,RC,J0295,HCPCS,55150011720,NDC,facility,both,1.5,GM,,31.62,23.72,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM SOLR 1 EACH VIAL,24748,CDM,636,RC,J0295,HCPCS,44567021110,NDC,facility,both,1.5,GM,,45.25,33.94,,,,,,,,,,Gross Charge Type: Pharmacy
CAMPHOR-MENTHOL 0.5-0.5 % LOTN,24810,CDM,250,RC,536126812,NDC,,,facility,both,222,ML,,44.55,33.41,,,,,,,,,,Gross Charge Type: Pharmacy
CAMPHOR-MENTHOL 0.5-0.5 % LOTN 222 ML BOTTLE,24810,CDM,250,RC,316022975,NDC,,,facility,both,222,ML,,48.35,36.26,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,767,ML,,99.63,74.72,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,700,ML,,95.35,71.51,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,433,ML,,77.25,57.94,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,967,ML,,112.7,84.52,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,600,ML,,88.57,66.43,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,1133,ML,,123.4,92.55,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,900,ML,,108.35,81.26,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,733,ML,,97.6,73.2,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,867,ML,,105.85,79.39,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,367,ML,,72.8,54.6,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,667,ML,,93.08,69.81,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,933,ML,,110.5,82.88,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,240,ML,,63.7,47.78,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,413,ML,,75.9,56.92,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,1000,ML,,114.8,86.1,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,33,ML,,49.75,37.31,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,200,ML,,61.45,46.09,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,1267,ML,,132,99,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,267,ML,,65.98,49.48,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,1033,ML,,116.95,87.71,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,800,ML,,101.87,76.4,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,467,ML,,79.43,59.57,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,300,ML,,68.25,51.19,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,833,ML,,103.97,77.97,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,1200,ML,,127.7,95.78,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,133,ML,,56.9,42.68,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,533,ML,,84.05,63.04,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,633,ML,,90.8,68.1,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,333,ML,,70.41,52.81,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,340,ML,,70.95,53.21,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,400,ML,,75,56.25,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,1067,ML,,119.15,89.36,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,320,ML,,69.6,52.2,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,233,ML,,63.7,47.78,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,500,ML,,81.74,61.31,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,1167,ML,,125.55,94.16,,,,,,,,,,Gross Charge Type: Pharmacy
"AMINO ACIDS 15% 15 % SOLN 2,000 ML PLAS CONT",24824,CDM,250,RC,338050206,NDC,,,facility,both,567,ML,,86.35,64.76,,,,,,,,,,Gross Charge Type: Pharmacy
ARGININE 10% (0.475 MEQ/ML) SOLN,24861,CDM,250,RC,MHS1ML,HCPCS,9043601,NDC,facility,both,1,ML,,0.51,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250-250-65 MG TABS,24970,CDM,250,RC,536132601,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250-250-65 MG TABS,24970,CDM,250,RC,536132601,NDC,,,facility,both,2,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
EPTIFIBATIDE 0.75 MG/ML SOLN,24975,CDM,636,RC,J1327,HCPCS,85113601,NDC,facility,both,5,ME,,18.85,14.14,,,,,,,,,,Gross Charge Type: Pharmacy
EPTIFIBATIDE 0.75 MG/ML SOLN,24975,CDM,636,RC,J1327,HCPCS,55150021899,NDC,facility,both,5,ME,,14.71,11.03,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 50 MG/ML SOLN 10 ML VIAL,24986,CDM,636,RC,J0133,HCPCS,55150015410,NDC,facility,both,5,ME,,0.31,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 50 MG/ML SOLN 10 ML VIAL,24986,CDM,636,RC,J0133,HCPCS,63323032510,NDC,facility,both,5,ME,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 50 MG/ML SOLN 20 ML VIAL,24986,CDM,636,RC,J0133,HCPCS,55150015520,NDC,facility,both,5,ME,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 50 MG/ML SOLN 20 ML VIAL,24986,CDM,636,RC,J0133,HCPCS,63323032520,NDC,facility,both,5,ME,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE 50 MG TABS,25043,CDM,636,RC,J7500,HCPCS,68084022901,NDC,facility,both,50,ME,,5.69,4.27,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM SOLR 1 EACH VIAL,25057,CDM,636,RC,J0457,HCPCS,63323040120,NDC,facility,both,100,ME,,11.87,8.9,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM SOLR,25058,CDM,636,RC,J0457,HCPCS,3257016,NDC,facility,both,100,ME,,9.87,7.4,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM SOLR,25058,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,both,100,ME,,9.36,7.02,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM SOLR 1 EACH VIAL,25058,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,both,100,ME,,9.36,7.02,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM SOLR 1 EACH VIAL,25058,CDM,636,RC,J0457,HCPCS,3257016,NDC,facility,both,100,ME,,9.87,7.4,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX E/DEXTROSE (4.25/5) 4.25 % SOLN 1,000 ML PLAS CONT",25065,CDM,250,RC,338114403,NDC,,,facility,both,2000,ML,,79.75,59.81,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX E/DEXTROSE (4.25/5) 4.25 % SOLN 1,000 ML PLAS CONT",25065,CDM,250,RC,338114403,NDC,,,facility,both,1000,ML,,105.35,79.01,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX E/DEXTROSE (5/15) 5 % SOLN 2,000 ML FLEX CONT",25075,CDM,250,RC,338112304,NDC,,,facility,both,1500,ML,,166.7,125.02,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX E/DEXTROSE (5/15) 5 % SOLN 2,000 ML FLEX CONT",25075,CDM,250,RC,338112304,NDC,,,facility,both,1000,ML,,166.7,125.02,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX E/DEXTROSE (5/15) 5 % SOLN 2,000 ML FLEX CONT",25075,CDM,250,RC,338112304,NDC,,,facility,both,2000,ML,,166.7,125.02,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX E/DEXTROSE (5/15): (BASE SOLN CONTAINS: NA 35 MEQ/L, K 30 MEQ/L, MG 5 MEQ/L, CA 4.5 MEQ/L, AC 80 MEQ/L, CL 39 MEQ/L, PO4 15 MMOL/L) 5 % SOLN 2,000 ML FLEX CONT",25075,CDM,250,RC,338112304,NDC,,,facility,both,2000,ML,,166.7,125.02,,,,,,,,,,Gross Charge Type: Pharmacy
BELLADONNA-OPIUM 30MG 16.2-30 MG SUPP,25147,CDM,250,RC,574704512,NDC,,,facility,both,1,UN,,48.85,36.64,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,65862011601,NDC,,,facility,both,2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,50268011011,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,65862011601,NDC,,,facility,both,3,UN,,2.53,1.9,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,65862011601,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,65862011601,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,43547033610,NDC,,,facility,both,4,UN,,2.12,1.59,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,50268011011,NDC,,,facility,both,4,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,65862011601,NDC,,,facility,both,4,UN,,2.04,1.53,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,50268011011,NDC,,,facility,both,0.5,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,43547033610,NDC,,,facility,both,1,UN,,5.9,4.42,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,43547033610,NDC,,,facility,both,2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,50268011011,NDC,,,facility,both,2,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,43547033610,NDC,,,facility,both,3,UN,,0.63,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG TABS,25151,CDM,250,RC,43547033610,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE SOLR 1 EACH VIAL,252,CDM,636,RC,J9075,HCPCS,10019095701,NDC,facility,both,5,ME,,4.47,3.35,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE SOLR 1 EACH VIAL,252,CDM,636,RC,J9070,HCPCS,10019095701,NDC,facility,both,5,ME,,87.94,65.95,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 100 MG CAPS,253,CDM,636,RC,J7502,HCPCS,78024115,NDC,facility,both,100,ME,,30.02,22.51,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML SOLN,25304,CDM,636,RC,J0515,HCPCS,68382086010,NDC,facility,both,1,ME,,84.7,63.52,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACETATE/BETAMETHASONE SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP,25326,CDM,636,RC,J0702,HCPCS,78206011801,NDC,facility,both,6,ME,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACETATE/BETAMETHASONE SODIUM PHOSPHATE 6 (3-3) MG/ML SUSP,25326,CDM,636,RC,J0702,HCPCS,517072001,NDC,facility,both,6,ME,,42.86,32.15,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,25326,CDM,517072001,NDC,,,,,facility,both,6,ML,,39.52,29.64,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG CHEW,25391,CDM,250,RC,904720546,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN SOLR 1 EACH VIAL,25396,CDM,636,RC,J9040,HCPCS,61703033218,NDC,facility,both,15,UN,,83.1,62.32,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN SOLR 1 EACH VIAL,25396,CDM,636,RC,J9040,HCPCS,16714088601,NDC,facility,both,15,UN,,59.78,44.84,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN SOLR 1 EACH VIAL,25396,CDM,636,RC,J9040,HCPCS,63323013610,NDC,facility,both,15,UN,,109.9,82.42,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 25 MG CAPS,254,CDM,636,RC,J7515,HCPCS,78024015,NDC,facility,both,25,ME,,6.86,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,FAMRXNC,HCPCS,12870000102,NDC,facility,both,2,UN,,19.15,14.36,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,12870000102,NDC,,,facility,both,4,UN,,10.15,7.61,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,FAMRXNC,HCPCS,12870000101,NDC,facility,both,2,UN,,4.73,3.55,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,12870000102,NDC,,,facility,both,8,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,12870000102,NDC,,,facility,both,3,UN,,13.15,9.86,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,FAMRXNC,HCPCS,12870000102,NDC,facility,both,3,UN,,13.15,9.86,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,12870000102,NDC,,,facility,both,6,UN,,7.12,5.34,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,12870000102,NDC,,,facility,both,2,UN,,19.15,14.36,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,FAMRXNC,HCPCS,12870000102,NDC,facility,both,1,UN,,37.05,27.79,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,12870000102,NDC,,,facility,both,5,UN,,8.34,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,FAMRXNC,HCPCS,12870000101,NDC,facility,both,1,UN,,4.73,3.55,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,12870000102,NDC,,,facility,both,1,UN,,22.88,17.16,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,12870000101,NDC,,,facility,both,1,UN,,3.03,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE-POT NITRATE 75-25 % MISC,25400,CDM,250,RC,12870000101,NDC,,,facility,both,2,UN,,4.73,3.55,,,,,,,,,,Gross Charge Type: Pharmacy
BROMOCRIPTINE 2.5 MG TABS,25421,CDM,250,RC,574010603,NDC,,,facility,both,1,UN,,14.55,10.91,,,,,,,,,,Gross Charge Type: Pharmacy
BROMOCRIPTINE 2.5 MG TABS,25421,CDM,250,RC,781532531,NDC,,,facility,both,1,UN,,14.15,10.61,,,,,,,,,,Gross Charge Type: Pharmacy
BROMOCRIPTINE 2.5 MG TABS,25421,CDM,250,RC,574010603,NDC,,,facility,both,0.5,UN,,11.25,8.44,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 3.75 MG KIT,25429,CDM,636,RC,J1950,HCPCS,74364103,NDC,facility,both,3.75,ME,,5275.75,3956.81,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML SOLN,25475,CDM,250,RC,mhs1mg,HCPCS,65219057004,NDC,facility,both,0.5,ME,,39.3,29.48,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML SOLN,25475,CDM,636,RC,J1939,HCPCS,68462046940,NDC,facility,both,0.5,ME,,14.92,11.19,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML SOLN,25475,CDM,636,RC,J1939,HCPCS,641600810,NDC,facility,both,0.5,ME,,16.86,12.64,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML SOLN,25475,CDM,250,RC,mhs1mg,HCPCS,641600810,NDC,facility,both,0.5,ME,,32.77,24.58,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML SOLN 4 ML VIAL,25475,CDM,636,RC,J1939,HCPCS,641600810,NDC,facility,both,0.5,ME,,10.78,8.08,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML SOLN 4 ML VIAL,25475,CDM,636,RC,J1939,HCPCS,68462046940,NDC,facility,both,0.5,ME,,10.67,8,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML SOLN 4 ML VIAL,25475,CDM,250,RC,mhs1mg,HCPCS,641600810,NDC,facility,both,0.5,ME,,22.97,17.23,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,69238149001,NDC,,,facility,both,3,UN,,2.98,2.24,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,50268013115,NDC,,,facility,both,3,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,904701606,NDC,,,facility,both,1,UN,,10,7.5,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,904701606,NDC,,,facility,both,3,UN,,4.77,3.57,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,832054111,NDC,,,facility,both,2,UN,,4.94,3.71,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,69238149001,NDC,,,facility,both,2,UN,,4.53,3.4,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,904701606,NDC,,,facility,both,4,UN,,4.08,3.06,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,832054111,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,50268013115,NDC,,,facility,both,2,UN,,6.02,4.52,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,69238149001,NDC,,,facility,both,6,UN,,2,1.5,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,68382052601,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,50268013115,NDC,,,facility,both,0.5,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,50268013115,NDC,,,facility,both,1,UN,,9.9,7.42,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,50268013115,NDC,,,facility,both,1.5,UN,,5.5,4.12,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,69238149001,NDC,,,facility,both,1,UN,,8.03,6.03,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,69238149001,NDC,,,facility,both,0.5,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,904701606,NDC,,,facility,both,1.5,UN,,5.58,4.18,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,50268013115,NDC,,,facility,both,4,UN,,4.01,3.01,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,832054111,NDC,,,facility,both,3,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,904701606,NDC,,,facility,both,2,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,832054111,NDC,,,facility,both,4,UN,,3.14,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,69238149001,NDC,,,facility,both,4,UN,,2.65,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,832054111,NDC,,,facility,both,0.5,UN,,7.85,5.89,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG TABS,25477,CDM,250,RC,904701606,NDC,,,facility,both,0.5,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,378623201,NDC,,,facility,both,1.5,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,904608561,NDC,,,facility,both,1.5,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,378623201,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,904608561,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,65862000601,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,904608561,NDC,,,facility,both,4,UN,,1.86,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,904608561,NDC,,,facility,both,3,UN,,2.37,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,378623201,NDC,,,facility,both,1,UN,,6.49,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,65862000601,NDC,,,facility,both,1.5,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,904608561,NDC,,,facility,both,2,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,904608561,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,378623201,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,65862000601,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG TABS,25482,CDM,250,RC,65862000601,NDC,,,facility,both,2,UN,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG CAPS,25484,CDM,250,RC,67877054360,NDC,,,facility,both,2,UN,,5.62,4.22,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG CAPS,25484,CDM,250,RC,93316006,NDC,,,facility,both,1,UN,,15.55,11.66,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG CAPS,25484,CDM,250,RC,67877054360,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG CAPS,25484,CDM,250,RC,57237009960,NDC,,,facility,both,2,UN,,5.62,4.22,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG CAPS,25484,CDM,250,RC,68180071160,NDC,,,facility,both,1,UN,,10.75,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG CAPS,25484,CDM,250,RC,57237009960,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN-HYDROCORTISONE 0.2-1 % SUSP 10 ML BOTTLE,25487,CDM,250,RC,MHS1ML,HCPCS,78085526,NDC,facility,both,1,ML,,60.39,45.29,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 100 MG TABS,25490,CDM,250,RC,904663661,NDC,,,facility,both,1.5,UN,,6.38,4.78,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 100 MG TABS,25490,CDM,250,RC,904663661,NDC,,,facility,both,3,UN,,5.73,4.3,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 100 MG TABS,25490,CDM,250,RC,904663661,NDC,,,facility,both,0.5,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 100 MG TABS,25490,CDM,250,RC,904663661,NDC,,,facility,both,1,UN,,11.1,8.32,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 100 MG TABS,25490,CDM,250,RC,904663661,NDC,,,facility,both,2,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,60687034001,NDC,,,facility,both,1,UN,,9.94,7.45,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,51079094320,NDC,,,facility,both,1,UN,,10.35,7.76,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,60687034001,NDC,,,facility,both,0.5,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,904663561,NDC,,,facility,both,0.5,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,60687034001,NDC,,,facility,both,2,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,904663561,NDC,,,facility,both,2,UN,,6.12,4.59,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,60687034001,NDC,,,facility,both,4,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,904663561,NDC,,,facility,both,1,UN,,10.05,7.54,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,904663561,NDC,,,facility,both,1.5,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 75 MG TABS,25491,CDM,250,RC,51079094320,NDC,,,facility,both,2,UN,,6.42,4.82,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG TABS,25493,CDM,250,RC,51079098620,NDC,,,facility,both,1,UN,,6.86,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG TABS,25493,CDM,250,RC,51079098620,NDC,,,facility,both,3,UN,,2.83,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG TABS,25493,CDM,250,RC,93005405,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG TABS,25493,CDM,250,RC,93005405,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG TABS,25493,CDM,250,RC,93005405,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG TABS,25493,CDM,250,RC,51079098620,NDC,,,facility,both,2,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG TABS,25493,CDM,250,RC,51079098620,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG TABS,25493,CDM,250,RC,51079098620,NDC,,,facility,both,1.5,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 5 MG TABS,25494,CDM,250,RC,51079098520,NDC,,,facility,both,4,UN,,2.12,1.59,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 5 MG TABS,25494,CDM,250,RC,51079098520,NDC,,,facility,both,1.5,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 5 MG TABS,25494,CDM,250,RC,51079098520,NDC,,,facility,both,3,UN,,2.65,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 5 MG TABS,25494,CDM,250,RC,51079098520,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 5 MG TABS,25494,CDM,250,RC,51079098520,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 5 MG TABS,25494,CDM,250,RC,51079098520,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
BUTAMBEN-TETRACAINE-BENZOCAINE 2-2-14 % AERO 20 G BOTTLE,25505,CDM,250,RC,10223020103,NDC,,,facility,both,20,GR,,207.75,155.81,,,,,,,,,,Gross Charge Type: Pharmacy
BUTORPHANOL 2 MG/ML SOLN,25512,CDM,636,RC,J0595,HCPCS,409162601,NDC,facility,both,1,ME,,25.12,18.84,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % OINT 3.5 G TUBE,25515,CDM,250,RC,MHS3.5gm,HCPCS,78084101,NDC,facility,both,3.5,GM,,381.1,285.82,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN 200 UNITS/ML SOLN,25591,CDM,636,RC,J0630,HCPCS,67457067502,NDC,facility,both,400,UN,,3179.75,2384.81,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,23155066203,NDC,,,facility,both,2,UN,,4.42,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,60687034501,NDC,,,facility,both,2,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,60687034501,NDC,,,facility,both,4,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,60687034501,NDC,,,facility,both,5,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,60687034501,NDC,,,facility,both,8,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,23155066203,NDC,,,facility,both,1,UN,,7.7,5.78,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,60687034501,NDC,,,facility,both,3,UN,,3.77,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,60687034501,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,23155066203,NDC,,,facility,both,4,UN,,2.51,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG CAPS,25599,CDM,250,RC,23155066203,NDC,,,facility,both,3,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,49348005539,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,70677107601,NDC,,,facility,both,0.666666667,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,70677107601,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,70677006501,NDC,,,facility,both,1,UN,,6.11,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,135017803,NDC,,,facility,both,2,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,70677006501,NDC,,,facility,both,2,UN,,2.98,2.24,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,49348005539,NDC,,,facility,both,2,UN,,3.2,2.4,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,536122922,NDC,,,facility,both,1,UN,,6.06,4.55,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,135017803,NDC,,,facility,both,1,UN,,6.13,4.6,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,536122522,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,70677107601,NDC,,,facility,both,2,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,536122522,NDC,,,facility,both,2,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 750 MG CHEW,25697,CDM,250,RC,536122922,NDC,,,facility,both,2,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
"CAPSAICIN (ZOSTRIX,TRIXAICIN) 0.075 % CREA 57 G TUBE",25721,CDM,250,RC,mhs1gm,HCPCS,536111825,NDC,facility,both,1,GM,,0.79,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 12.5 MG TABS,25723,CDM,250,RC,904710561,NDC,,,facility,both,1,UN,,10.15,7.61,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 12.5 MG TABS,25723,CDM,250,RC,904710561,NDC,,,facility,both,2,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 25 MG TABS,25724,CDM,250,RC,31722014201,NDC,,,facility,both,0.5,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 25 MG TABS,25724,CDM,250,RC,31722014201,NDC,,,facility,both,3,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 25 MG TABS,25724,CDM,250,RC,31722014201,NDC,,,facility,both,1.5,UN,,5.22,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 25 MG TABS,25724,CDM,250,RC,31722014201,NDC,,,facility,both,4,UN,,3.31,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 25 MG TABS,25724,CDM,250,RC,60687031511,NDC,,,facility,both,1.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 25 MG TABS,25724,CDM,250,RC,31722014201,NDC,,,facility,both,1,UN,,8.76,6.57,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 25 MG TABS,25724,CDM,250,RC,31722014201,NDC,,,facility,both,2,UN,,5.46,4.1,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 25 MG TABS,25724,CDM,250,RC,904710661,NDC,,,facility,both,1,UN,,10.35,7.76,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST 250 MCG/ML SOLN,25770,CDM,250,RC,MHS1ML,HCPCS,9085608,NDC,facility,both,1,ML,,834,625.5,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST 250 MCG/ML SOLN,25770,CDM,250,RC,MHS1ML,HCPCS,70121168007,NDC,facility,both,1,ML,,964.65,723.49,,,,,,,,,,Gross Charge Type: Pharmacy
CEFOXITIN SOLR,25868,CDM,636,RC,J0694,HCPCS,25021010910,NDC,facility,both,1,GM,,49.65,37.24,,,,,,,,,,Gross Charge Type: Pharmacy
CEFOXITIN SOLR,25868,CDM,636,RC,J0694,HCPCS,44567024525,NDC,facility,both,1,GM,,67.36,50.52,,,,,,,,,,Gross Charge Type: Pharmacy
CEFOXITIN SOLR,25868,CDM,636,RC,J0694,HCPCS,63323034125,NDC,facility,both,1,GM,,67.6,50.7,,,,,,,,,,Gross Charge Type: Pharmacy
CEFOXITIN SOLR,25870,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,both,1,GM,,33.91,25.43,,,,,,,,,,Gross Charge Type: Pharmacy
CEFOXITIN SOLR 1 EACH VIAL,25870,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,both,1,GM,,34,25.5,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME SOLR 1 EACH VIAL,25883,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,both,500,ME,,28.62,21.47,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME SOLR 1 EACH VIAL,25883,CDM,636,RC,J0713,HCPCS,409508216,NDC,facility,both,500,ME,,27.72,20.79,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME SOLR 1 EACH VIAL,25883,CDM,250,RC,25021012720,NDC,,,facility,both,500,ME,,57.25,42.94,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 G SOLR,25898,CDM,636,RC,J0696,HCPCS,60505614804,NDC,facility,both,250,ME,,10.94,8.2,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 G SOLR,25898,CDM,636,RC,J0696,HCPCS,409733201,NDC,facility,both,250,ME,,8.24,6.18,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 G SOLR,25898,CDM,636,RC,J0696,HCPCS,781320885,NDC,facility,both,250,ME,,34.25,25.69,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 G SOLR,25898,CDM,636,RC,J0696,HCPCS,781320895,NDC,facility,both,250,ME,,12.23,9.17,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 G SOLR 1 EACH VIAL,25898,CDM,636,RC,J0696,HCPCS,60505614804,NDC,facility,both,250,ME,,10.3,7.72,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 G SOLR 1 EACH VIAL,25898,CDM,636,RC,J0696,HCPCS,781320895,NDC,facility,both,250,ME,,12.21,9.16,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 G SOLR 1 EACH VIAL,25898,CDM,636,RC,J0696,HCPCS,781320885,NDC,facility,both,250,ME,,34.17,25.63,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 G SOLR 1 EACH VIAL,25898,CDM,636,RC,J0696,HCPCS,409733201,NDC,facility,both,250,ME,,8.03,6.02,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SODIUM 1 G IJ SOLR,25898,CDM,409733211,NDC,,,,,facility,both,250,EA,,7.97,5.98,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SODIUM 1 G IJ SOLR,25898,CDM,60505614804,NDC,,,,,facility,both,250,EA,,1.5,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SODIUM 1 G IJ SOLR,25898,CDM,781320885,NDC,,,,,facility,both,250,EA,,18.11,13.58,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SODIUM 1 G IJ SOLR,25898,CDM,409733201,NDC,,,,,facility,both,250,EA,,5.12,3.84,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SODIUM 1 G IJ SOLR,25898,CDM,409733201,NDC,,,,,facility,both,250,EA,,65,48.75,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 2 G SOLR,25899,CDM,636,RC,J0696,HCPCS,781320995,NDC,facility,both,250,ME,,8.37,6.28,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 2 G SOLR,25899,CDM,636,RC,J0696,HCPCS,409733503,NDC,facility,both,250,ME,,5.29,3.97,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 2 G SOLR,25899,CDM,636,RC,J0696,HCPCS,60505614904,NDC,facility,both,250,ME,,7.14,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 2 G SOLR 1 EACH VIAL,25899,CDM,636,RC,J0696,HCPCS,781320995,NDC,facility,both,250,ME,,8.37,6.28,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 2 G SOLR 1 EACH VIAL,25899,CDM,636,RC,J0696,HCPCS,409733503,NDC,facility,both,250,ME,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 2 G SOLR 1 EACH VIAL,25899,CDM,636,RC,J0696,HCPCS,143985625,NDC,facility,both,250,ME,,4.84,3.63,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SOLR,25899,CDM,636,RC,J0696,HCPCS,60505614904,NDC,facility,both,250,ME,,7.14,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SOLR,25899,CDM,636,RC,J0696,HCPCS,143985625,NDC,facility,both,250,ME,,4.84,3.63,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SOLR,25899,CDM,636,RC,J0696,HCPCS,409733503,NDC,facility,both,250,ME,,5.29,3.97,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SOLR,25899,CDM,636,RC,J0696,HCPCS,781320995,NDC,facility,both,250,ME,,8.38,6.28,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SOLR 1 EACH VIAL,25899,CDM,636,RC,J0696,HCPCS,409733503,NDC,facility,both,250,ME,,5.27,3.95,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SOLR 1 EACH VIAL,25899,CDM,636,RC,J0696,HCPCS,60505614904,NDC,facility,both,250,ME,,7.14,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SOLR 1 EACH VIAL,25899,CDM,636,RC,J0696,HCPCS,143985625,NDC,facility,both,250,ME,,4.84,3.63,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SOLR 1 EACH VIAL,25899,CDM,636,RC,J0696,HCPCS,781320995,NDC,facility,both,250,ME,,8.37,6.28,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 SOLR,25900,CDM,636,RC,J0696,HCPCS,409733701,NDC,facility,both,250,ME,,12.59,9.44,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 SOLR 1 EACH VIAL,25900,CDM,636,RC,J0696,HCPCS,409733701,NDC,facility,both,250,ME,,16.88,12.66,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SODIUM 250 MG IJ SOLR,25900,CDM,409733701,NDC,,,,,facility,both,250,EA,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 SOLR,25901,CDM,636,RC,J0696,HCPCS,409733801,NDC,facility,both,250,ME,,15.35,11.51,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SODIUM 500 MG IJ SOLR,25901,CDM,409733801,NDC,,,,,facility,both,250,EA,,3.41,2.56,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE SODIUM 500 MG IJ SOLR,25901,CDM,409733811,NDC,,,,,facility,both,250,EA,,15.35,11.51,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME 250 MG TABS,25906,CDM,250,RC,65862069960,NDC,,,facility,both,1,UN,,8.96,6.72,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME 250 MG TABS,25906,CDM,250,RC,65862069960,NDC,,,facility,both,2,UN,,5.04,3.78,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG TABS,25942,CDM,250,RC,904671761,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG TABS,25942,CDM,250,RC,51079059720,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG TABS,25942,CDM,250,RC,16714079902,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG TABS,25942,CDM,250,RC,16714079902,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG TABS,25942,CDM,250,RC,904671761,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG TABS,25942,CDM,250,RC,51079059720,NDC,,,facility,both,3,UN,,2.87,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG TABS,25942,CDM,250,RC,51079059720,NDC,,,facility,both,2,UN,,3.92,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG TABS,25942,CDM,250,RC,51079059720,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE HCL 10 MG OR TABS,25942,CDM,51079059720,NDC,,,,,facility,both,2,EA,,3.92,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE HCL 10 MG OR TABS,25942,CDM,51079059720,NDC,,,,,facility,both,1,EA,,10.05,7.54,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE HCL 10 MG OR TABS,25942,CDM,16714079902,NDC,,,,,facility,both,1,EA,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE 0.12 % SOLN,25984,CDM,250,RC,MHS15ML,HCPCS,69339013819,NDC,facility,both,15,ML,,7.14,5.35,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE 0.12 % SOLN 473 ML BOTTLE,25984,CDM,250,RC,MHS15ML,HCPCS,116200116,NDC,facility,both,15,ML,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE 250 MG/5ML SUSP,26005,CDM,250,RC,MHS1ML,HCPCS,65649031112,NDC,facility,both,1,ML,,5.67,4.25,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SOLR,26006,CDM,636,RC,J1205,HCPCS,25021030566,NDC,facility,both,500,ME,,130.3,97.72,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SOLR,26006,CDM,636,RC,J1205,HCPCS,517182001,NDC,facility,both,500,ME,,463.7,347.78,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SOLR,26006,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,both,500,ME,,123.69,92.77,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SOLR,26006,CDM,636,RC,J1205,HCPCS,47335033040,NDC,facility,both,500,ME,,130.05,97.54,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G PACK,26225,CDM,250,RC,42806026698,NDC,,,facility,both,1,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G PACK,26225,CDM,250,RC,42806026698,NDC,,,facility,both,0.5,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
CICLOPIROX 0.77 % CREA,26259,CDM,250,RC,MHS1GM,HCPCS,68462029717,NDC,facility,both,1,GM,,3.01,2.26,,,,,,,,,,Gross Charge Type: Pharmacy
CICLOPIROX 0.77 % CREA 15 G TUBE,26259,CDM,250,RC,MHS1GM,HCPCS,45802013835,NDC,facility,both,1,GM,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,26285,CDM,250,RC,MHS0.5ML,HCPCS,69315030805,NDC,facility,both,0.5,ML,,4.9,3.67,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % SOLN 5 ML BOTTLE,26285,CDM,250,RC,MHS0.5ML,HCPCS,61314065605,NDC,facility,both,0.5,ML,,3.85,2.89,,,,,,,,,,Gross Charge Type: Pharmacy
CLARITHROMYCIN 500 MG TABS,26298,CDM,250,RC,65862022660,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50ML SOLN,26321,CDM,250,RC,MHS1ML,HCPCS,781328909,NDC,facility,both,300,ME,,1.6,1.2,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50ML SOLN,26321,CDM,250,RC,J0736,HCPCS,781328909,NDC,facility,both,300,ME,,40.05,30.04,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50ML SOLN,26321,CDM,636,RC,J0736,HCPCS,781328909,NDC,facility,both,300,ME,,39.72,29.79,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50ML SOLN,26322,CDM,250,RC,MHS1ML,HCPCS,781329009,NDC,facility,both,300,ME,,1.74,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50ML SOLN,26322,CDM,250,RC,J0736,HCPCS,781329009,NDC,facility,both,300,ME,,28.93,21.7,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50ML SOLN,26322,CDM,250,RC,MHS1ML,HCPCS,338381424,NDC,facility,both,300,ME,,1.23,0.92,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50ML SOLN,26322,CDM,636,RC,J0737,HCPCS,338381424,NDC,facility,both,300,ME,,20.52,15.39,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50ML SOLN,26322,CDM,636,RC,J0736,HCPCS,781329009,NDC,facility,both,300,ME,,28.93,21.7,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBETASOL 0.05 % OINT 15 G TUBE,26348,CDM,250,RC,MHS1GM,HCPCS,51672125901,NDC,facility,both,1,GM,,6.65,4.98,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 25 MG CAPS,26357,CDM,250,RC,16714084901,NDC,,,facility,both,2,UN,,11.42,8.57,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 25 MG CAPS,26357,CDM,250,RC,68084079025,NDC,,,facility,both,2,UN,,21.9,16.42,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 25 MG CAPS,26357,CDM,250,RC,68084079025,NDC,,,facility,both,1,UN,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG TABS,26364,CDM,250,RC,63739026310,NDC,,,facility,both,2,UN,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG TABS,26364,CDM,250,RC,63739026310,NDC,,,facility,both,0.5,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG TABS,26364,CDM,250,RC,63739026310,NDC,,,facility,both,0.25,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG TABS,26364,CDM,250,RC,63739026310,NDC,,,facility,both,1,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG TABS,26365,CDM,250,RC,16729013700,NDC,,,facility,both,1,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 2 MG TABS,26366,CDM,250,RC,16729013800,NDC,,,facility,both,1,UN,,5.22,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 10 MG TROC,26387,CDM,250,RC,54414622,NDC,,,facility,both,1,UN,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 10 MG TROC,26387,CDM,250,RC,54814622,NDC,,,facility,both,1,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG TABS,26407,CDM,250,RC,51079092220,NDC,,,facility,both,3,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG TABS,26407,CDM,250,RC,51079092220,NDC,,,facility,both,3.5,UN,,3.78,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG TABS,26407,CDM,250,RC,378086001,NDC,,,facility,both,2,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG TABS,26407,CDM,250,RC,51079092220,NDC,,,facility,both,1.5,UN,,1.65,1.24,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG TABS,26407,CDM,250,RC,51079092220,NDC,,,facility,both,1,UN,,9.33,7,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG TABS,26407,CDM,250,RC,51079092220,NDC,,,facility,both,2.5,UN,,4.37,3.27,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG TABS,26407,CDM,250,RC,51079092220,NDC,,,facility,both,0.5,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG TABS,26407,CDM,250,RC,51079092220,NDC,,,facility,both,2,UN,,6.02,4.52,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 25 MG TABS,26408,CDM,250,RC,51079092120,NDC,,,facility,both,4,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 25 MG TABS,26408,CDM,250,RC,51079092120,NDC,,,facility,both,2,UN,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 25 MG TABS,26408,CDM,250,RC,51079092120,NDC,,,facility,both,3,UN,,3.53,2.65,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 25 MG TABS,26408,CDM,250,RC,51079092120,NDC,,,facility,both,10,UN,,1.66,1.25,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 25 MG TABS,26408,CDM,250,RC,51079092120,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
COLLAGENASE 250 UNIT/GM OINT 30 G TUBE,26503,CDM,250,RC,mhs1gm,HCPCS,50484001030,NDC,facility,both,1,GM,,13.44,10.08,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN SOLR,26525,CDM,636,RC,J0834,HCPCS,548590000,NDC,facility,both,0.25,ME,,320.45,240.34,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN SOLR,26525,CDM,636,RC,J0834,HCPCS,781344095,NDC,facility,both,0.25,ME,,94.8,71.1,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN SOLR 1 EACH VIAL,26525,CDM,636,RC,J0834,HCPCS,781344095,NDC,facility,both,0.25,ME,,57.44,43.08,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN SOLR 1 EACH VIAL,26525,CDM,636,RC,J0834,HCPCS,548590000,NDC,facility,both,0.25,ME,,288.61,216.46,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPENTOLATE-PHENYLEPHRINE 0.2%-1% SOLN 2 ML BOTTLE,26577,CDM,250,RC,MHS2ML,HCPCS,65035902,NDC,facility,both,2,ML,,72.25,54.19,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE IN STERILE WATER SOLR 1 EACH VIAL,26607,CDM,250,RC,78670000367,NDC,,,facility,both,7,UN,,177.11,132.83,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,68084030021,NDC,,,facility,both,1,UN,,11.2,8.4,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,68084030021,NDC,,,facility,both,4,UN,,5.06,3.8,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,68084030021,NDC,,,facility,both,2,UN,,7.17,5.38,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,904721104,NDC,,,facility,both,6,UN,,3.89,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,115441101,NDC,,,facility,both,2,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,904721104,NDC,,,facility,both,1,UN,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,904721104,NDC,,,facility,both,4,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,68084030021,NDC,,,facility,both,6,UN,,4.28,3.21,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,115441101,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,904721104,NDC,,,facility,both,3,UN,,5.38,4.04,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,68084030021,NDC,,,facility,both,3,UN,,5.8,4.35,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE 25 MG CAPS,26609,CDM,250,RC,904721104,NDC,,,facility,both,2,UN,,4.74,3.55,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,1,ML,,23.66,17.75,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,0.75,ML,,27.83,20.87,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,0.25,ML,,83.15,62.36,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,0.75,ML,,30.3,22.72,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,0.25,ML,,102.15,76.61,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,1,ML,,45.66,34.25,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,1,ML,,26.14,19.6,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,0.125,ML,,66.55,49.91,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,0.25,ML,,63.35,47.51,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,0.5,ML,,58.18,43.63,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,0.25,ML,,56.4,42.3,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,0.5,ML,,38.65,28.99,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,0.5,ML,,37.48,28.11,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,0.5,ML,,36.18,27.13,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,0.125,ML,,76.1,57.08,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,0.5,ML,,77.22,57.92,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML AMPULE,26669,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,4,ML,,16.77,12.57,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML AMPULE,26669,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,6,ML,,16.03,12.02,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML AMPULE,26669,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,both,5,ML,,16.34,12.26,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,7,ML,,37.55,28.17,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,4,ML,,37.97,28.48,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,1,ML,,23.66,17.75,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,0.5,ML,,58.18,43.63,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,5,ML,,39.5,29.63,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,both,5,ML,,13.74,10.3,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,3,ML,,36.1,27.07,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 1 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,70095002601,NDC,facility,both,1,ML,,45.66,34.25,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,8,ML,,14.44,10.83,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,7.04,ML,,14.15,10.61,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,8.84,ML,,14.11,10.58,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,1,ML,,64.74,48.55,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,5.175,ML,,14.82,11.12,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,5.75,ML,,14.85,11.14,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,5,ML,,15.1,11.33,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,0.5,ML,,37.48,28.11,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,4.75,ML,,15.21,11.41,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,6.2,ML,,14.62,10.96,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,6.75,ML,,14.62,10.97,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,8.77,ML,,14.4,10.8,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,7.5,ML,,14.5,10.88,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,7,ML,,49.36,37.02,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,7.5,ML,,47.69,35.77,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,8.75,ML,,14.37,10.78,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,0.5,ML,,77.22,57.92,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,6.32,ML,,14.3,10.73,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,6.41,ML,,50.96,38.22,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,7,ML,,14.58,10.93,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,4.76,ML,,15.24,11.43,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,9.63,ML,,14.14,10.6,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,7.75,ML,,14.47,10.85,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,5.43,ML,,14.76,11.07,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,7.25,ML,,14.54,10.9,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,4.5,ML,,58.83,44.12,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,4.74,ML,,15.18,11.39,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,2,ML,,12.62,9.46,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,55566230000,NDC,facility,both,6,ML,,53.54,40.16,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,5.84,ML,,14.43,10.82,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,6,ML,,14.79,11.09,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,4,ML,,15.62,11.72,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,4.47,ML,,15.19,11.39,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,6.5,ML,,14.67,11,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,9,ML,,14.35,10.76,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL,26669,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,both,4.5,ML,,15.28,11.46,,,,,,,,,,Gross Charge Type: Pharmacy
DESONIDE 0.05 % LOTN 59 ML BOTTLE,26672,CDM,250,RC,472080302,NDC,,,facility,both,59,ML,,170.1,127.58,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 %  AND LACTATED RINGERS SOLN,26764,CDM,636,RC,J7121,HCPCS,990792909,NDC,facility,both,1000,ML,,23.7,17.78,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 %  AND LACTATED RINGERS SOLN,26764,CDM,636,RC,J7121,HCPCS,338012504,NDC,facility,both,1000,ML,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 %  AND LACTATED RINGERS SOLN 1,000 ML FLEX CONT",26764,CDM,636,RC,J7121,HCPCS,338012504,NDC,facility,both,1000,ML,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.9 MEQ/L-%-% SOLN,26771,CDM,636,RC,J3480,HCPCS,990710709,NDC,facility,both,1000,ML,,2.56,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.9 MEQ/L-%-% SOLN,26771,CDM,636,RC,J3480,HCPCS,338080304,NDC,facility,both,1000,ML,,1.95,1.46,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.9 MEQ/L-%-% SOLN,26771,CDM,636,RC,J3480,HCPCS,338080304,NDC,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.9 MEQ/L-%-% SOLN,26771,CDM,636,RC,J3480,HCPCS,338080304,NDC,facility,both,75,ML,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.9 MEQ/L-%-% SOLN,26771,CDM,636,RC,J3480,HCPCS,338080304,NDC,facility,both,50,ML,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% AND 0.2% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.2 MEQ/L-%-% SOLN,26776,CDM,250,RC,338066304,NDC,,,facility,both,1000,ML,,19.5,14.62,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% AND 0.45% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.45 MEQ/L-%-% SOLN,26777,CDM,250,RC,MHS250ML,HCPCS,338067104,NDC,facility,both,250,ML,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% AND 0.45% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.45 MEQ/L-%-% SOLN,26777,CDM,250,RC,MHS250ML,HCPCS,990790209,NDC,facility,both,250,ML,,6.41,4.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5% AND 0.45% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.45 MEQ/L-%-% SOLN 1,000 ML FLEX CONT",26777,CDM,250,RC,MHS250ML,HCPCS,338067104,NDC,facility,both,250,ML,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% AND 0.45% NACL WITH KCL 40 MEQ/L SOLUTION 40-5-0.45 MEQ/L-%-% SOLN,26783,CDM,250,RC,990790409,NDC,,,facility,both,1000,ML,,25.65,19.24,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% AND 0.45% NACL WITH KCL 40 MEQ/L SOLUTION 40-5-0.45 MEQ/L-%-% SOLN,26783,CDM,250,RC,338067504,NDC,,,facility,both,1000,ML,,19.5,14.62,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 66-10 % SOLN,26819,CDM,636,RC,Q9963,HCPCS,270044540,NDC,facility,both,1,ML,,0.17,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 66-10 % SOLN,26819,CDM,255,RC,Q9963,HCPCS,270044540,NDC,facility,both,1,ML,,0.16,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB SOLR 1 EACH VIAL,26984,CDM,636,RC,J1745,HCPCS,57894003001,NDC,facility,both,10,ME,,274.86,206.14,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Heliox Gas (Per Day),2700000001,CDM,270,RC,,,,,facility,both,,,,1261.05,945.79,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Medical Gas (Per Day),2700000002,CDM,270,RC,,,,,facility,both,,,,516.6,387.45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Medical Supplies,2700000002_270,CDM,270,RC,,,,,facility,both,,,,516.6,387.45,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Medical Gas W. Aerosol (Per Day),2700000003,CDM,270,RC,,,,,facility,both,,,,525,393.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Medical Supplies,2700000003_270,CDM,270,RC,,,,,facility,both,,,,525,393.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Bed Posey Canopy Rental,2700000004,CDM,270,RC,,,,,facility,both,,,,175.35,131.51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Medical Supplies,2700000004_270,CDM,270,RC,,,,,facility,both,,,,175.35,131.51,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Mattress Envision Rental,2700000006,CDM,270,RC,,,,,facility,both,,,,133.35,100.01,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bed Rental Envella Daily,2700000007,CDM,270,RC,,,,,facility,both,,,,368.55,276.41,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Medical Supplies,2700000007_270,CDM,270,RC,,,,,facility,both,,,,368.55,276.41,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Rental Bed Compella Daily,2700000008,CDM,270,RC,,,,,facility,both,,,,343.35,257.51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Medical Supplies,2700000008_270,CDM,270,RC,,,,,facility,both,,,,343.35,257.51,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Wound Care Vacuum Rental,2700000009,CDM,270,RC,,,,,facility,both,,,,217.35,163.01,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Medical Supplies,2700000009_270,CDM,270,RC,,,,,facility,both,,,,217.35,163.01,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_274,CDM,274,RC,,,,,facility,both,,,,1072.05,804.04,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_A8001_274,CDM,274,RC,A8001,HCPCS,,,facility,both,,,,661.5,496.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0003_274,CDM,274,RC,L0003,HCPCS,,,facility,both,,,,187.19,140.39,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0172_274,CDM,274,RC,L0172,HCPCS,,,facility,both,,,,378,283.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0174_274,CDM,274,RC,L0174,HCPCS,,,facility,both,,,,798,598.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0190_274,CDM,274,RC,L0190,HCPCS,,,facility,both,,,,2047.5,1535.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0200_274,CDM,274,RC,L0200,HCPCS,,,facility,both,,,,2289,1716.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0457_274,CDM,274,RC,L0457,HCPCS,,,facility,both,,,,2887.5,2165.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0464_270,CDM,270,RC,L0464,HCPCS,,,facility,both,,,,4099.73,3074.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0464_274,CDM,274,RC,L0464,HCPCS,,,facility,both,,,,4094.03,3070.52,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0486_274,CDM,274,RC,L0486,HCPCS,,,facility,both,,,,4987.5,3740.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0627_274,CDM,274,RC,L0627,HCPCS,,,facility,both,,,,1090.95,818.21,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0631_274,CDM,274,RC,L0631,HCPCS,,,facility,both,,,,2832.9,2124.68,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0648_274,CDM,274,RC,L0648,HCPCS,,,facility,both,,,,2832.9,2124.68,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0710_274,CDM,274,RC,L0710,HCPCS,,,facility,both,,,,7096.95,5322.71,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L0999_274,CDM,274,RC,L0999,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L1686_274,CDM,274,RC,L1686,HCPCS,,,facility,both,,,,3032.4,2274.3,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L1832_274,CDM,274,RC,L1832,HCPCS,,,facility,both,,,,2013.9,1510.42,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L1833_274,CDM,274,RC,L1833,HCPCS,,,facility,both,,,,2013.9,1510.42,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L1930_274,CDM,274,RC,L1930,HCPCS,,,facility,both,,,,955.5,716.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L1932_274,CDM,274,RC,L1932,HCPCS,,,facility,both,,,,3052.35,2289.26,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L1940_274,CDM,274,RC,L1940,HCPCS,,,facility,both,,,,1837.5,1378.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L1960_274,CDM,274,RC,L1960,HCPCS,,,facility,both,,,,1911,1433.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L2128_274,CDM,274,RC,L2128,HCPCS,,,facility,both,,,,7106.4,5329.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L2275_274,CDM,274,RC,L2275,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L2624_274,CDM,274,RC,L2624,HCPCS,,,facility,both,,,,1144.5,858.38,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L2820_274,CDM,274,RC,L2820,HCPCS,,,facility,both,,,,304.5,228.38,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L2830_274,CDM,274,RC,L2830,HCPCS,,,facility,both,,,,325.5,244.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L3761_274,CDM,274,RC,L3761,HCPCS,,,facility,both,,,,1211,908.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L4397_274,CDM,274,RC,L4397,HCPCS,,,facility,both,,,,598.5,448.88,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L5450_274,CDM,274,RC,L5450,HCPCS,,,facility,both,,,,1154.19,865.64,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L5460_274,CDM,274,RC,L5460,HCPCS,,,facility,both,,,,1542.45,1156.84,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,2700000013_L8465_274,CDM,274,RC,L8465,HCPCS,,,facility,both,,,,357,267.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_270,CDM,270,RC,,,,,facility,both,,,,129.23,96.92,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_272,CDM,272,RC,,,,,facility,both,,,,538,403.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4206_270,CDM,270,RC,A4206,HCPCS,,,facility,both,,,,6.29,4.72,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4212_270,CDM,270,RC,A4212,HCPCS,,,facility,both,,,,9.23,6.92,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4212_272,CDM,272,RC,A4212,HCPCS,,,facility,both,,,,10.96,8.22,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4213_270,CDM,270,RC,A4213,HCPCS,,,facility,both,,,,24.21,18.16,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4215_270,CDM,270,RC,A4215,HCPCS,,,facility,both,,,,135.42,101.56,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4221_270,CDM,270,RC,A4221,HCPCS,,,facility,both,,,,30.01,22.51,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4284_270,CDM,270,RC,A4284,HCPCS,,,facility,both,,,,9.8,7.35,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4300_270,CDM,270,RC,A4300,HCPCS,,,facility,both,,,,116.6,87.45,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4314_270,CDM,270,RC,A4314,HCPCS,,,facility,both,,,,91.52,68.64,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4314_272,CDM,272,RC,A4314,HCPCS,,,facility,both,,,,89.8,67.35,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4328_270,CDM,270,RC,A4328,HCPCS,,,facility,both,,,,49.61,37.21,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4331_270,CDM,270,RC,A4331,HCPCS,,,facility,both,,,,49.2,36.9,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4333_270,CDM,270,RC,A4333,HCPCS,,,facility,both,,,,15.77,11.83,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4334_270,CDM,270,RC,A4334,HCPCS,,,facility,both,,,,15.98,11.98,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4338_270,CDM,270,RC,A4338,HCPCS,,,facility,both,,,,35.38,26.54,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4340_270,CDM,270,RC,A4340,HCPCS,,,facility,both,,,,80.21,60.16,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4346_270,CDM,270,RC,A4346,HCPCS,,,facility,both,,,,59.5,44.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4349_270,CDM,270,RC,A4349,HCPCS,,,facility,both,,,,68.76,51.57,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4355_270,CDM,270,RC,A4355,HCPCS,,,facility,both,,,,49.93,37.45,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4357_270,CDM,270,RC,A4357,HCPCS,,,facility,both,,,,12.33,9.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4364_270,CDM,270,RC,A4364,HCPCS,,,facility,both,,,,7.96,5.97,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4406_270,CDM,270,RC,A4406,HCPCS,,,facility,both,,,,5.83,4.37,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4409_270,CDM,270,RC,A4409,HCPCS,,,facility,both,,,,3.62,2.72,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4414_270,CDM,270,RC,A4414,HCPCS,,,facility,both,,,,143.74,107.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4425_270,CDM,270,RC,A4425,HCPCS,,,facility,both,,,,3.68,2.76,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4430_270,CDM,270,RC,A4430,HCPCS,,,facility,both,,,,6.08,4.56,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4432_270,CDM,270,RC,A4432,HCPCS,,,facility,both,,,,1.83,1.37,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4452_270,CDM,270,RC,A4452,HCPCS,,,facility,both,,,,9.89,7.42,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4550_270,CDM,270,RC,A4550,HCPCS,,,facility,both,,,,424.91,318.68,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4556_270,CDM,270,RC,A4556,HCPCS,,,facility,both,,,,21.3,15.98,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4556_272,CDM,272,RC,A4556,HCPCS,,,facility,both,,,,19.68,14.76,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4565_270,CDM,270,RC,A4565,HCPCS,,,facility,both,,,,12.86,9.64,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4566_270,CDM,270,RC,A4566,HCPCS,,,facility,both,,,,54.81,41.11,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4580_270,CDM,270,RC,A4580,HCPCS,,,facility,both,,,,3,2.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4590_270,CDM,270,RC,A4590,HCPCS,,,facility,both,,,,49.48,37.11,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4615_270,CDM,270,RC,A4615,HCPCS,,,facility,both,,,,65.57,49.18,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4618_270,CDM,270,RC,A4618,HCPCS,,,facility,both,,,,121.67,91.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4620_270,CDM,270,RC,A4620,HCPCS,,,facility,both,,,,133.41,100.06,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4629_270,CDM,270,RC,A4629,HCPCS,,,facility,both,,,,10.06,7.54,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4648_270,CDM,270,RC,A4648,HCPCS,,,facility,both,,,,43.78,32.84,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4649_270,CDM,270,RC,A4649,HCPCS,,,facility,both,,,,131.76,98.82,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4649_272,CDM,272,RC,A4649,HCPCS,,,facility,both,,,,50.49,37.87,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4657_270,CDM,270,RC,A4657,HCPCS,,,facility,both,,,,10.03,7.52,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A4671_270,CDM,270,RC,A4671,HCPCS,,,facility,both,,,,217.43,163.07,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A5071_270,CDM,270,RC,A5071,HCPCS,,,facility,both,,,,117.81,88.36,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A5200_270,CDM,270,RC,A5200,HCPCS,,,facility,both,,,,41.98,31.48,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6214_270,CDM,270,RC,A6214,HCPCS,,,facility,both,,,,24.84,18.63,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6250_270,CDM,270,RC,A6250,HCPCS,,,facility,both,,,,26.96,20.22,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6257_270,CDM,270,RC,A6257,HCPCS,,,facility,both,,,,15.49,11.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6258_270,CDM,270,RC,A6258,HCPCS,,,facility,both,,,,3.47,2.6,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6266_270,CDM,270,RC,A6266,HCPCS,,,facility,both,,,,8.76,6.57,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6402_270,CDM,270,RC,A6402,HCPCS,,,facility,both,,,,2.61,1.96,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6403_270,CDM,270,RC,A6403,HCPCS,,,facility,both,,,,6.03,4.52,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6413_270,CDM,270,RC,A6413,HCPCS,,,facility,both,,,,9.03,6.77,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6450_270,CDM,270,RC,A6450,HCPCS,,,facility,both,,,,27.09,20.32,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6454_270,CDM,270,RC,A6454,HCPCS,,,facility,both,,,,10.37,7.78,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6455_270,CDM,270,RC,A6455,HCPCS,,,facility,both,,,,16.57,12.43,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6457_270,CDM,270,RC,A6457,HCPCS,,,facility,both,,,,7.35,5.51,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6530_270,CDM,270,RC,A6530,HCPCS,,,facility,both,,,,15.08,11.31,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6533_270,CDM,270,RC,A6533,HCPCS,,,facility,both,,,,15.42,11.56,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A6550_270,CDM,270,RC,A6550,HCPCS,,,facility,both,,,,203.56,152.67,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A7000_270,CDM,270,RC,A7000,HCPCS,,,facility,both,,,,66.43,49.82,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A7002_270,CDM,270,RC,A7002,HCPCS,,,facility,both,,,,124.79,93.59,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A7008_270,CDM,270,RC,A7008,HCPCS,,,facility,both,,,,25.92,19.44,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A7521_270,CDM,270,RC,A7521,HCPCS,,,facility,both,,,,780.43,585.32,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_A9279_270,CDM,270,RC,A9279,HCPCS,,,facility,both,,,,24.96,18.72,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_B4035_270,CDM,270,RC,B4035,HCPCS,,,facility,both,,,,19.73,14.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_B4087_270,CDM,270,RC,B4087,HCPCS,,,facility,both,,,,133.81,100.36,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_B9999_270,CDM,270,RC,B9999,HCPCS,,,facility,both,,,,229.13,171.85,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1713_270,CDM,270,RC,C1713,HCPCS,,,facility,both,,,,4643.62,3482.72,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1715_272,CDM,272,RC,C1715,HCPCS,,,facility,both,,,,449.95,337.46,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1725_270,CDM,270,RC,C1725,HCPCS,,,facility,both,,,,787.5,590.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1726_270,CDM,270,RC,C1726,HCPCS,,,facility,both,,,,643.03,482.27,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1729_270,CDM,270,RC,C1729,HCPCS,,,facility,both,,,,111.47,83.6,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1729_272,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,61.69,46.27,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1730_270,CDM,270,RC,C1730,HCPCS,,,facility,both,,,,2296.88,1722.66,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1751_270,CDM,270,RC,C1751,HCPCS,,,facility,both,,,,324.34,243.26,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1757_270,CDM,270,RC,C1757,HCPCS,,,facility,both,,,,7078.58,5308.94,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1766_270,CDM,270,RC,C1766,HCPCS,,,facility,both,,,,2887.5,2165.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1769_270,CDM,270,RC,C1769,HCPCS,,,facility,both,,,,247.78,185.84,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1776_270,CDM,270,RC,C1776,HCPCS,,,facility,both,,,,510.3,382.72,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1781_270,CDM,270,RC,C1781,HCPCS,,,facility,both,,,,974.54,730.9,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1819_270,CDM,270,RC,C1819,HCPCS,,,facility,both,,,,117.16,87.87,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1819_278,CDM,278,RC,C1819,HCPCS,,,facility,both,,,,85.67,64.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1887_270,CDM,270,RC,C1887,HCPCS,,,facility,both,,,,370.54,277.9,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1889_270,CDM,270,RC,C1889,HCPCS,,,facility,both,,,,217.16,162.87,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1889_278,CDM,278,RC,C1889,HCPCS,,,facility,both,,,,5785.5,4339.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1892_270,CDM,270,RC,C1892,HCPCS,,,facility,both,,,,121.8,91.35,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1894_270,CDM,270,RC,C1894,HCPCS,,,facility,both,,,,168.49,126.37,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C1894_272,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,222.34,166.76,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C2618_270,CDM,270,RC,C2618,HCPCS,,,facility,both,,,,2151.49,1613.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C2627_270,CDM,270,RC,C2627,HCPCS,,,facility,both,,,,81.05,60.79,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C2630_270,CDM,270,RC,C2630,HCPCS,,,facility,both,,,,2495.15,1871.36,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_C9771_270,CDM,270,RC,C9771,HCPCS,,,facility,both,,,,3664.53,2748.4,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_E0190_270,CDM,270,RC,E0190,HCPCS,,,facility,both,,,,363.68,272.76,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_E0218_270,CDM,270,RC,E0218,HCPCS,,,facility,both,,,,104.39,78.29,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_E0485_270,CDM,270,RC,E0485,HCPCS,,,facility,both,,,,187.1,140.32,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_E0574_270,CDM,270,RC,E0574,HCPCS,,,facility,both,,,,187.83,140.87,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_E0673_270,CDM,270,RC,E0673,HCPCS,,,facility,both,,,,65.8,49.35,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_E0700_270,CDM,270,RC,E0700,HCPCS,,,facility,both,,,,34.21,25.66,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_E0710_270,CDM,270,RC,E0710,HCPCS,,,facility,both,,,,109.82,82.36,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_E0770_270,CDM,270,RC,E0770,HCPCS,,,facility,both,,,,426.39,319.79,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_J3490_270,CDM,270,RC,J3490,HCPCS,,,facility,both,,,,135.98,101.98,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_K0609_270,CDM,270,RC,K0609,HCPCS,,,facility,both,,,,176.29,132.22,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L0120_270,CDM,270,RC,L0120,HCPCS,,,facility,both,,,,37.66,28.24,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L0625_270,CDM,270,RC,L0625,HCPCS,,,facility,both,,,,45.32,33.99,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L1830_270,CDM,270,RC,L1830,HCPCS,,,facility,both,,,,119.51,89.63,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L1830_274,CDM,274,RC,L1830,HCPCS,,,facility,both,,,,114.53,85.9,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L1832_270,CDM,270,RC,L1832,HCPCS,,,facility,both,,,,157.3,117.98,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L3260_270,CDM,270,RC,L3260,HCPCS,,,facility,both,,,,24.41,18.31,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L3670_270,CDM,270,RC,L3670,HCPCS,,,facility,both,,,,182.32,136.74,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L3807_270,CDM,270,RC,L3807,HCPCS,,,facility,both,,,,63.37,47.53,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L3908_270,CDM,270,RC,L3908,HCPCS,,,facility,both,,,,63.32,47.49,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L4350_270,CDM,270,RC,L4350,HCPCS,,,facility,both,,,,68.8,51.6,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L4397_270,CDM,270,RC,L4397,HCPCS,,,facility,both,,,,186.4,139.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_L8501_270,CDM,270,RC,L8501,HCPCS,,,facility,both,,,,270.48,202.86,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_Q4051_270,CDM,270,RC,Q4051,HCPCS,,,facility,both,,,,8.65,6.49,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_S1015_270,CDM,270,RC,S1015,HCPCS,,,facility,both,,,,22.66,17,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_S1015_272,CDM,272,RC,S1015,HCPCS,,,facility,both,,,,20.73,15.55,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27000000S1_S8999_270,CDM,270,RC,S8999,HCPCS,,,facility,both,,,,29.97,22.48,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
DOBUTAMINE 12.5 MG/ML SOLN 20 ML VIAL,27045,CDM,636,RC,J1250,HCPCS,409234401,NDC,facility,both,250,ME,,17.73,13.3,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE 12.5 MG/ML SOLN 20 ML VIAL,27045,CDM,636,RC,J1250,HCPCS,409234402,NDC,facility,both,250,ME,,37.52,28.14,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE 12.5 MG/ML SOLN 20 ML VIAL,27045,CDM,636,RC,J1250,HCPCS,409234488,NDC,facility,both,250,ME,,27.57,20.68,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE HCL 12.5 MG/ML IV SOLN,27045,CDM,409234402,NDC,,,,,facility,both,250,ML,,35.32,26.49,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE HCL 12.5 MG/ML IV SOLN,27045,CDM,409234488,NDC,,,,,facility,both,250,ML,,11,8.25,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE HCL 12.5 MG/ML IV SOLN,27045,CDM,409234401,NDC,,,,,facility,both,250,ML,,26.4,19.8,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG TABS,27068,CDM,250,RC,904552261,NDC,,,facility,both,4,UN,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG TABS,27068,CDM,250,RC,904552261,NDC,,,facility,both,3,UN,,3.67,2.75,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG TABS,27068,CDM,250,RC,904552261,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG TABS,27068,CDM,250,RC,904552261,NDC,,,facility,both,2,UN,,4.95,3.71,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG TABS,27070,CDM,250,RC,904552461,NDC,,,facility,both,3,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG TABS,27070,CDM,250,RC,904552461,NDC,,,facility,both,1.25,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG TABS,27070,CDM,250,RC,904552461,NDC,,,facility,both,1.5,UN,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG TABS,27070,CDM,250,RC,904552461,NDC,,,facility,both,2,UN,,4.98,3.73,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG TABS,27070,CDM,250,RC,904552461,NDC,,,facility,both,0.75,UN,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG TABS,27070,CDM,250,RC,904552461,NDC,,,facility,both,1,UN,,8.56,6.42,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG TABS,27070,CDM,250,RC,904552461,NDC,,,facility,both,0.5,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
DRONABINOL 2.5 MG CAPS,27083,CDM,250,RC,42858086706,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
DRONABINOL 2.5 MG CAPS,27083,CDM,250,RC,42858086706,NDC,,,facility,both,2,UN,,6.02,4.52,,,,,,,,,,Gross Charge Type: Pharmacy
DRONABINOL 2.5 MG CAPS,27083,CDM,250,RC,67877075360,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
Noncdm Charge Record Medical Supplies,27100000S1_E0604_271,CDM,271,RC,E0604,HCPCS,,,facility,both,,,,118.11,88.58,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
ENALAPRIL 10 MG TABS,27120,CDM,250,RC,16714044401,NDC,,,facility,both,0.5,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL 10 MG TABS,27120,CDM,250,RC,16714044401,NDC,,,facility,both,1,UN,,8.3,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL 10 MG TABS,27120,CDM,250,RC,16714044401,NDC,,,facility,both,2,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL 2.5 MG TABS,27121,CDM,250,RC,43547054510,NDC,,,facility,both,1,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL 5 MG TABS,27123,CDM,250,RC,16714044301,NDC,,,facility,both,2,UN,,4.28,3.21,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL 5 MG TABS,27123,CDM,250,RC,16714044301,NDC,,,facility,both,1,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL 5 MG TABS,27123,CDM,250,RC,16714044301,NDC,,,facility,both,4,UN,,2.38,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML INJ,27126,CDM,250,RC,MHS1ML,HCPCS,143978710,NDC,facility,both,1,ML,,38.82,29.12,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML INJ,27126,CDM,250,RC,MHS1ML,HCPCS,143978610,NDC,facility,both,1,ML,,45.16,33.87,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE 20 MG TABS,27143,CDM,250,RC,62332006230,NDC,,,facility,both,1,UN,,14.5,10.88,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE 20 MG TABS,27143,CDM,250,RC,70748013006,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE 20 MG TABS,27143,CDM,250,RC,62332006230,NDC,,,facility,both,0.5,UN,,11.25,8.44,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE 20 MG TABS,27143,CDM,250,RC,70748013006,NDC,,,facility,both,0.5,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 10,000 UNITS/ML SOLN",27182,CDM,636,RC,Q4081,HCPCS,59676031001,NDC,facility,both,1000,UN,,4.16,3.12,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 10,000 UNITS/ML SOLN",27182,CDM,636,RC,J0885,HCPCS,59676031001,NDC,facility,both,1000,UN,,36.8,27.6,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,27182,CDM,59676031000,NDC,,,,,facility,both,1000,ML,,35,26.25,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,27182,CDM,59676031001,NDC,,,,,facility,both,1000,ML,,40.98,30.74,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 2,000 UNITS/ML SOLN",27183,CDM,636,RC,J0885,HCPCS,55513012610,NDC,facility,both,1000,UN,,73.95,55.46,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 4,000 UNITS/ML SOLN",27185,CDM,636,RC,J0885,HCPCS,59676030401,NDC,facility,both,1000,UN,,80.64,60.48,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 4,000 UNITS/ML SOLN 1 ML VIAL",27185,CDM,636,RC,J0885,HCPCS,55513014810,NDC,facility,both,1000,UN,,54.28,40.71,,,,,,,,,,Gross Charge Type: Pharmacy
Noncdm Charge Record Medical Supplies,27200000S1_272,CDM,272,RC,,,,,facility,both,,,,209.63,157.22,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_A4338_272,CDM,272,RC,A4338,HCPCS,,,facility,both,,,,34.99,26.24,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_A4550_272,CDM,272,RC,A4550,HCPCS,,,facility,both,,,,202.12,151.59,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_A4556_272,CDM,272,RC,A4556,HCPCS,,,facility,both,,,,18.6,13.95,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_A4649_272,CDM,272,RC,A4649,HCPCS,,,facility,both,,,,115.32,86.49,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1052_272,CDM,272,RC,C1052,HCPCS,,,facility,both,,,,6562.5,4921.88,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1713_272,CDM,272,RC,C1713,HCPCS,,,facility,both,,,,133.66,100.24,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1714_272,CDM,272,RC,C1714,HCPCS,,,facility,both,,,,8911.88,6683.91,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1715_272,CDM,272,RC,C1715,HCPCS,,,facility,both,,,,449.95,337.46,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1724_272,CDM,272,RC,C1724,HCPCS,,,facility,both,,,,3340.75,2505.56,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1725_272,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,941.54,706.16,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1726_272,CDM,272,RC,C1726,HCPCS,,,facility,both,,,,685.77,514.33,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1729_272,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,188.29,141.22,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1730_272,CDM,272,RC,C1730,HCPCS,,,facility,both,,,,2658.31,1993.73,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1731_272,CDM,272,RC,C1731,HCPCS,,,facility,both,,,,6867,5150.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1732_272,CDM,272,RC,C1732,HCPCS,,,facility,both,,,,5443.93,4082.95,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1747_272,CDM,272,RC,C1747,HCPCS,,,facility,both,,,,2234.14,1675.6,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1748_272,CDM,272,RC,C1748,HCPCS,,,facility,both,,,,7817.34,5863,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1753_272,CDM,272,RC,C1753,HCPCS,,,facility,both,,,,2172.92,1629.69,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1757_272,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,3955.04,2966.28,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1758_272,CDM,272,RC,C1758,HCPCS,,,facility,both,,,,54.45,40.84,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1759_272,CDM,272,RC,C1759,HCPCS,,,facility,both,,,,7752.91,5814.68,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1761_272,CDM,272,RC,C1761,HCPCS,,,facility,both,,,,11972.92,8979.69,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1766_272,CDM,272,RC,C1766,HCPCS,,,facility,both,,,,2488.68,1866.51,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1769_272,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,248.33,186.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1769_278,CDM,278,RC,C1769,HCPCS,,,facility,both,,,,82.61,61.96,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1773_272,CDM,272,RC,C1773,HCPCS,,,facility,both,,,,1619.62,1214.72,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1782_272,CDM,272,RC,C1782,HCPCS,,,facility,both,,,,2020.66,1515.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1787_272,CDM,272,RC,C1787,HCPCS,,,facility,both,,,,893.02,669.76,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1789_272,CDM,272,RC,C1789,HCPCS,,,facility,both,,,,3654,2740.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1830_272,CDM,272,RC,C1830,HCPCS,,,facility,both,,,,747.79,560.84,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1886_272,CDM,272,RC,C1886,HCPCS,,,facility,both,,,,5571.56,4178.67,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1887_272,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,74.62,55.96,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1888_272,CDM,272,RC,C1888,HCPCS,,,facility,both,,,,12010.57,9007.93,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1889_272,CDM,272,RC,C1889,HCPCS,,,facility,both,,,,256.44,192.33,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1893_272,CDM,272,RC,C1893,HCPCS,,,facility,both,,,,97.99,73.49,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1894_272,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,229.89,172.42,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C1894_278,CDM,278,RC,C1894,HCPCS,,,facility,both,,,,123.65,92.74,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C2618_272,CDM,272,RC,C2618,HCPCS,,,facility,both,,,,3929.75,2947.31,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C2623_272,CDM,272,RC,C2623,HCPCS,,,facility,both,,,,3491.25,2618.44,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C2627_272,CDM,272,RC,C2627,HCPCS,,,facility,both,,,,112.81,84.61,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C2628_272,CDM,272,RC,C2628,HCPCS,,,facility,both,,,,407.15,305.36,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C2630_272,CDM,272,RC,C2630,HCPCS,,,facility,both,,,,9205.4,6904.05,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27200000S1_C9765_272,CDM,272,RC,C9765,HCPCS,,,facility,both,,,,9056.25,6792.19,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
CEFADROXIL 500 MG CAPS,27212,CDM,250,RC,16714038801,NDC,,,facility,both,1,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
CEFADROXIL 500 MG CAPS,27212,CDM,250,RC,16714038801,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG CAPS,27213,CDM,250,RC,50268015115,NDC,,,facility,both,2,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG CAPS,27213,CDM,250,RC,50268015115,NDC,,,facility,both,4,UN,,2.64,1.98,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG CAPS,27213,CDM,250,RC,50268015115,NDC,,,facility,both,3,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG CAPS,27213,CDM,250,RC,50268015115,NDC,,,facility,both,1,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS,27214,CDM,250,RC,50268015215,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS,27214,CDM,250,RC,50268015215,NDC,,,facility,both,1,UN,,8.02,6.02,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS,27214,CDM,250,RC,60687016301,NDC,,,facility,both,1,UN,,7.58,5.68,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS,27214,CDM,250,RC,60687016301,NDC,,,facility,both,2,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS,27214,CDM,250,RC,65862001901,NDC,,,facility,both,2,UN,,4.15,3.11,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS,27214,CDM,250,RC,93314701,NDC,,,facility,both,1,UN,,7.31,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS,27214,CDM,250,RC,65862001901,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS,27214,CDM,250,RC,93314701,NDC,,,facility,both,2,UN,,4.28,3.21,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5ML SUSR,27218,CDM,250,RC,MHS5ML,HCPCS,62135048142,NDC,facility,both,5,ML,,25.34,19,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE IN STERILE WATER 20 MEQ/100ML SOLN,27240,CDM,636,RC,J3480,HCPCS,338070548,NDC,facility,both,100,ML,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,990707714,NDC,facility,both,100,ML,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,338070341,NDC,facility,both,25,ML,,5.26,3.95,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,14789010708,NDC,facility,both,100,ML,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,338070341,NDC,facility,both,30,ML,,5.26,3.95,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,338070341,NDC,facility,both,209.9166667,ML,,1.46,1.09,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,338070341,NDC,facility,both,150,ML,,2.1,1.57,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,338070341,NDC,facility,both,100,ML,,2.9,2.17,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,338070341,NDC,facility,both,21.80555556,ML,,5.26,3.95,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,338070341,NDC,facility,both,50,ML,,5.26,3.95,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,14789010708,NDC,facility,both,50,ML,,9.18,6.89,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/50ML SOLN,27243,CDM,636,RC,J3480,HCPCS,990707714,NDC,facility,both,50,ML,,5.74,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG TABS,27270,CDM,250,RC,378145401,NDC,,,facility,both,1,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG TABS,27270,CDM,250,RC,555088602,NDC,,,facility,both,0.75,UN,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG TABS,27270,CDM,250,RC,555088602,NDC,,,facility,both,1.25,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG TABS,27270,CDM,250,RC,555088602,NDC,,,facility,both,8,UN,,1.12,0.84,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG TABS,27270,CDM,250,RC,555088602,NDC,,,facility,both,2,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG TABS,27270,CDM,250,RC,555088602,NDC,,,facility,both,1,UN,,5.44,4.08,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG TABS,27270,CDM,250,RC,378145401,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG TABS,27270,CDM,250,RC,555088602,NDC,,,facility,both,3,UN,,2.48,1.86,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG TABS,27270,CDM,250,RC,555088602,NDC,,,facility,both,4,UN,,1.98,1.48,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.1 MG/GM CREA 42.5 G TUBE,27275,CDM,250,RC,MHS1GM,HCPCS,430375414,NDC,facility,both,1,GM,,12.08,9.06,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE MICRONIZED 67 MG CAPS,27284,CDM,250,RC,68462058001,NDC,,,facility,both,2.985074627,UN,,2.9,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE MICRONIZED 67 MG CAPS,27284,CDM,250,RC,68462058001,NDC,,,facility,both,3,UN,,2.9,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE MICRONIZED 67 MG CAPS,27284,CDM,250,RC,27241011804,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE MICRONIZED 67 MG CAPS,27284,CDM,250,RC,68462058001,NDC,,,facility,both,2.014925373,UN,,2.68,2.01,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE MICRONIZED 67 MG CAPS,27284,CDM,250,RC,68462058001,NDC,,,facility,both,2,UN,,4.02,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE MICRONIZED 67 MG CAPS,27284,CDM,250,RC,68462058001,NDC,,,facility,both,1.940298508,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE MICRONIZED 67 MG CAPS,27284,CDM,250,RC,27241011804,NDC,,,facility,both,2.014925373,UN,,2.87,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE MICRONIZED 67 MG CAPS,27284,CDM,250,RC,68462058001,NDC,,,facility,both,1,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS SOLR,27291,CDM,636,RC,J1410,HCPCS,46074905,NDC,facility,both,25,ME,,1028.85,771.64,,,,,,,,,,Gross Charge Type: Pharmacy
ESTROGENS CONJUGATED 0.3 MG TABS,27292,CDM,250,RC,46110081,NDC,,,facility,both,1,UN,,20,15,,,,,,,,,,Gross Charge Type: Pharmacy
ESTROGENS CONJUGATED 0.625 MG TABS,27293,CDM,250,RC,46110281,NDC,,,facility,both,1,UN,,20,15,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM SOLR,2731,CDM,636,RC,J2185,HCPCS,70121145407,NDC,facility,both,100,ME,,12.62,9.46,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM SOLR 1 EACH VIAL,2731,CDM,636,RC,J2185,HCPCS,70121145407,NDC,facility,both,100,ME,,12.62,9.46,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN 8 MG TABS,27314,CDM,250,RC,62332034230,NDC,,,facility,both,1,UN,,10.55,7.91,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN 8 MG TABS,27314,CDM,250,RC,60687011925,NDC,,,facility,both,0.5,UN,,11.9,8.92,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN 16 MG TABS,27317,CDM,250,RC,33342011607,NDC,,,facility,both,1,UN,,9.9,7.42,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN 32 MG TABS,27318,CDM,250,RC,33342011707,NDC,,,facility,both,1,UN,,11.3,8.48,,,,,,,,,,Gross Charge Type: Pharmacy
ETHOSUXIMIDE 250 MG CAPS,27319,CDM,250,RC,69452015220,NDC,,,facility,both,2,UN,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM SOLR,2733,CDM,636,RC,J2185,HCPCS,55150020830,NDC,facility,both,100,ME,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM SOLR,2733,CDM,636,RC,J2185,HCPCS,72572041601,NDC,facility,both,100,ME,,5.58,4.19,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM SOLR 1 EACH VIAL,2733,CDM,636,RC,J2185,HCPCS,72572041601,NDC,facility,both,100,ME,,6.47,4.85,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM SOLR 1 EACH VIAL,2733,CDM,636,RC,J2185,HCPCS,55150020830,NDC,facility,both,100,ME,,4.54,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
ETODOLAC 400 MG TABS,27343,CDM,250,RC,51672401801,NDC,,,facility,both,1,UN,,9.95,7.46,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,61442012101,NDC,,,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,172572870,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,904719361,NDC,,,facility,both,2,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,65862085901,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,904719361,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,904719361,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,172572860,NDC,,,facility,both,2,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,904719306,NDC,,,facility,both,2,UN,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,63739064510,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,172572870,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,65862085901,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,172572860,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,60687059501,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,60687059501,NDC,,,facility,both,1,UN,,7.27,5.45,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,63739064510,NDC,,,facility,both,2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,63739064510,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,60687059501,NDC,,,facility,both,0.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,904719306,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,172572860,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,904719306,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,65862085901,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG TABS,27367,CDM,250,RC,61442012101,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 600 MG TABS,27384,CDM,250,RC,72578005716,NDC,,,facility,both,1,UN,,10.5,7.88,,,,,,,,,,Gross Charge Type: Pharmacy
Noncdm Charge Record Medical Supplies,2740000001_L0464_274,CDM,274,RC,L0464,HCPCS,,,facility,both,,,,4099.73,3074.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L0120_274,CDM,274,RC,L0120,HCPCS,,,facility,both,,,,37.66,28.24,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L0172_274,CDM,274,RC,L0172,HCPCS,,,facility,both,,,,222.04,166.53,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L0174_274,CDM,274,RC,L0174,HCPCS,,,facility,both,,,,53.2,39.9,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L0625_274,CDM,274,RC,L0625,HCPCS,,,facility,both,,,,46.04,34.53,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L1820_274,CDM,274,RC,L1820,HCPCS,,,facility,both,,,,188.65,141.49,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L1830_274,CDM,274,RC,L1830,HCPCS,,,facility,both,,,,110.78,83.08,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L1832_274,CDM,274,RC,L1832,HCPCS,,,facility,both,,,,221.37,166.03,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L1833_274,CDM,274,RC,L1833,HCPCS,,,facility,both,,,,2013.9,1510.42,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L3260_274,CDM,274,RC,L3260,HCPCS,,,facility,both,,,,24.41,18.31,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L3650_274,CDM,274,RC,L3650,HCPCS,,,facility,both,,,,24.29,18.22,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L3660_274,CDM,274,RC,L3660,HCPCS,,,facility,both,,,,54.59,40.94,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L3670_274,CDM,274,RC,L3670,HCPCS,,,facility,both,,,,184.57,138.43,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L3807_274,CDM,274,RC,L3807,HCPCS,,,facility,both,,,,169.39,127.04,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L3809_274,CDM,274,RC,L3809,HCPCS,,,facility,both,,,,169.39,127.04,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L3908_274,CDM,274,RC,L3908,HCPCS,,,facility,both,,,,63.91,47.93,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L4350_274,CDM,274,RC,L4350,HCPCS,,,facility,both,,,,68.8,51.6,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L4361_274,CDM,274,RC,L4361,HCPCS,,,facility,both,,,,227.3,170.48,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L4386_274,CDM,274,RC,L4386,HCPCS,,,facility,both,,,,141.84,106.38,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L4396_274,CDM,274,RC,L4396,HCPCS,,,facility,both,,,,62.4,46.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L4397_274,CDM,274,RC,L4397,HCPCS,,,facility,both,,,,186.4,139.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L8000_274,CDM,274,RC,L8000,HCPCS,,,facility,both,,,,156.24,117.18,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27400000S1_L8501_274,CDM,274,RC,L8501,HCPCS,,,facility,both,,,,270.48,202.86,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
FINASTERIDE 5 MG TABS,27454,CDM,250,RC,904683006,NDC,,,facility,both,1,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG TABS,27454,CDM,250,RC,60687042865,NDC,,,facility,both,1,UN,,9.6,7.2,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG TABS,27454,CDM,250,RC,67877028890,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG TABS,27454,CDM,250,RC,67877028890,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG TABS,27454,CDM,250,RC,65862014990,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG TABS,27454,CDM,250,RC,904683006,NDC,,,facility,both,0.5,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG TABS,27454,CDM,250,RC,50268031415,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG TABS,27454,CDM,250,RC,60687042865,NDC,,,facility,both,0.5,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG TABS,27459,CDM,250,RC,54001120,NDC,,,facility,both,1,UN,,9.2,6.9,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG TABS,27459,CDM,250,RC,54001120,NDC,,,facility,both,1.5,UN,,5,3.75,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG TABS,27459,CDM,250,RC,54001120,NDC,,,facility,both,0.5,UN,,8.25,6.19,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 150 MG TABS,27460,CDM,250,RC,54001221,NDC,,,facility,both,1,UN,,10.25,7.69,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 150 MG TABS,27460,CDM,250,RC,54001221,NDC,,,facility,both,0.5,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG TABS,27471,CDM,250,RC,68084072801,NDC,,,facility,both,1,UN,,10.16,7.62,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG TABS,27471,CDM,250,RC,904650061,NDC,,,facility,both,4,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG TABS,27471,CDM,250,RC,904650061,NDC,,,facility,both,2,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG TABS,27471,CDM,250,RC,68084072801,NDC,,,facility,both,4,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG TABS,27471,CDM,250,RC,904650061,NDC,,,facility,both,3,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG TABS,27471,CDM,250,RC,68084072801,NDC,,,facility,both,2,UN,,6.18,4.63,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG TABS,27471,CDM,250,RC,68084072801,NDC,,,facility,both,3,UN,,5.03,3.77,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG TABS,27471,CDM,250,RC,904650061,NDC,,,facility,both,1,UN,,9.49,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG TABS,27472,CDM,250,RC,904650161,NDC,,,facility,both,3,UN,,6.38,4.79,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG TABS,27472,CDM,250,RC,904650161,NDC,,,facility,both,1,UN,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG TABS,27472,CDM,250,RC,16714069302,NDC,,,facility,both,2,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG TABS,27472,CDM,250,RC,904650161,NDC,,,facility,both,2,UN,,7.85,5.89,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN NS 200-0.9 MG/100ML-% SOLN,27476,CDM,636,RC,J1450,HCPCS,25021018482,NDC,facility,both,200,ME,,53.5,40.12,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN NS 200-0.9 MG/100ML-% SOLN 100 ML FLEX CONT,27476,CDM,636,RC,J1450,HCPCS,25021018482,NDC,facility,both,200,ME,,53.5,40.12,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN NS 400-0.9 MG/200ML-% SOLN,27477,CDM,636,RC,J1450,HCPCS,409468812,NDC,facility,both,200,ME,,34.58,25.93,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN NS 400-0.9 MG/200ML-% SOLN,27477,CDM,636,RC,J1450,HCPCS,25021018487,NDC,facility,both,200,ME,,27.9,20.92,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN NS 400-0.9 MG/200ML-% SOLN 100 ML FLEX CONT,27477,CDM,636,RC,J1450,HCPCS,25021018482,NDC,facility,both,200,ME,,46.15,34.61,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN NS 400-0.9 MG/200ML-% SOLN 200 ML FLEX CONT,27477,CDM,636,RC,J1450,HCPCS,409468812,NDC,facility,both,200,ME,,25.2,18.9,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN NS 400-0.9 MG/200ML-% SOLN 200 ML FLEX CONT,27477,CDM,636,RC,J1450,HCPCS,25021018487,NDC,facility,both,200,ME,,25.92,19.44,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG TABS,27481,CDM,250,RC,68084028801,NDC,,,facility,both,2,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG TABS,27481,CDM,250,RC,68084028801,NDC,,,facility,both,0.5,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG TABS,27481,CDM,250,RC,68084028801,NDC,,,facility,both,4,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG TABS,27481,CDM,250,RC,68084028801,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
Noncdm Charge Record Medical Supplies,27500000S1_275,CDM,275,RC,,,,,facility,both,,,,3855,2891.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27500000S1_C1721_275,CDM,275,RC,C1721,HCPCS,,,facility,both,,,,33956.97,25467.73,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27500000S1_C1722_275,CDM,275,RC,C1722,HCPCS,,,facility,both,,,,31992.94,23994.7,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27500000S1_C1785_275,CDM,275,RC,C1785,HCPCS,,,facility,both,,,,9899.46,7424.6,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27500000S1_C1786_275,CDM,275,RC,C1786,HCPCS,,,facility,both,,,,25774.58,19330.94,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27500000S1_C1882_275,CDM,275,RC,C1882,HCPCS,,,facility,both,,,,47165.85,35374.39,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27500000S1_C1887_278,CDM,278,RC,C1887,HCPCS,,,facility,both,,,,4716.25,3537.19,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27500000S1_C1894_272,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,1575,1181.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27500000S1_C1898_275,CDM,275,RC,C1898,HCPCS,,,facility,both,,,,1260,945,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27500000S1_C2621_275,CDM,275,RC,C2621,HCPCS,,,facility,both,,,,17601.31,13200.98,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,904734661,NDC,,,facility,both,4,UN,,1.98,1.48,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,16714072102,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,904734661,NDC,,,facility,both,3,UN,,2.48,1.86,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,65862019301,NDC,,,facility,both,3,UN,,2.42,1.81,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,904734661,NDC,,,facility,both,1,UN,,5.95,4.47,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,16714072102,NDC,,,facility,both,1,UN,,5.79,4.34,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,65862019301,NDC,,,facility,both,1,UN,,6.26,4.7,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,65862019301,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,16714072102,NDC,,,facility,both,3,UN,,2.22,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,50111064801,NDC,,,facility,both,3,UN,,2.37,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,50111064801,NDC,,,facility,both,1,UN,,5.73,4.3,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,50111064801,NDC,,,facility,both,4,UN,,1.86,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,16714072102,NDC,,,facility,both,4,UN,,1.72,1.29,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,904734661,NDC,,,facility,both,2,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,50111064801,NDC,,,facility,both,2,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG CAPS,27521,CDM,250,RC,65862019301,NDC,,,facility,both,4,UN,,1.91,1.43,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 50 MG TABS,27553,CDM,250,RC,60505016501,NDC,,,facility,both,2,UN,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 50 MG TABS,27553,CDM,250,RC,60505016501,NDC,,,facility,both,5,UN,,2.37,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 50 MG TABS,27553,CDM,250,RC,60505016501,NDC,,,facility,both,0.5,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 50 MG TABS,27553,CDM,250,RC,60505016501,NDC,,,facility,both,3,UN,,3.42,2.56,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 50 MG TABS,27553,CDM,250,RC,60505016501,NDC,,,facility,both,1,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 50 MG TABS,27553,CDM,250,RC,60505016501,NDC,,,facility,both,2.5,UN,,3.27,2.45,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 10 MG TABS,27575,CDM,250,RC,69097085605,NDC,,,facility,both,2,UN,,3.92,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 10 MG TABS,27575,CDM,250,RC,69097085605,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
Noncdm Charge Record Medical Supplies,27600000S1_V2632_276,CDM,276,RC,V2632,HCPCS,,,facility,both,,,,458.64,343.98,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
BENZONATATE 100 MG CAPS,2762,CDM,250,RC,60687034601,NDC,,,facility,both,2,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG CAPS,2762,CDM,250,RC,42806071401,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG CAPS,2762,CDM,250,RC,42806071401,NDC,,,facility,both,2,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG CAPS,2762,CDM,250,RC,60687034601,NDC,,,facility,both,1,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TABS,27642,CDM,250,RC,904663761,NDC,,,facility,both,4,UN,,2.5,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TABS,27642,CDM,250,RC,904663761,NDC,,,facility,both,1,UN,,7.7,5.78,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TABS,27642,CDM,250,RC,51079081020,NDC,,,facility,both,1,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TABS,27642,CDM,250,RC,904663761,NDC,,,facility,both,2,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TABS,27642,CDM,250,RC,904663761,NDC,,,facility,both,0.5,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TABS,27642,CDM,250,RC,51079081020,NDC,,,facility,both,0.5,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG TABS,27681,CDM,250,RC,904670961,NDC,,,facility,both,1,UN,,10.05,7.54,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG TABS,27681,CDM,250,RC,904670961,NDC,,,facility,both,2,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG TABS,27681,CDM,250,RC,904670961,NDC,,,facility,both,4,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG TABS,27681,CDM,250,RC,904670961,NDC,,,facility,both,0.5,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG TABS,27681,CDM,250,RC,13107001401,NDC,,,facility,both,1,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
GOSERELIN 3.6 MG IMPL,27691,CDM,636,RC,J9202,HCPCS,70720095036,NDC,facility,both,3.6,ME,,3255.67,2441.75,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 80 MG CHEW,277,CDM,250,RC,904579146,NDC,,,facility,both,4,UN,,1.82,1.37,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 80 MG CHEW,277,CDM,250,RC,904579146,NDC,,,facility,both,8.125,UN,,0.94,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 80 MG CHEW,277,CDM,250,RC,904579146,NDC,,,facility,both,3.5,UN,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 80 MG CHEW,277,CDM,250,RC,904579146,NDC,,,facility,both,6,UN,,1.32,0.99,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 80 MG CHEW,277,CDM,250,RC,904579146,NDC,,,facility,both,3,UN,,2.33,1.75,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 80 MG CHEW,277,CDM,250,RC,904579146,NDC,,,facility,both,4.5,UN,,1.49,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 80 MG CHEW,277,CDM,250,RC,904579146,NDC,,,facility,both,5,UN,,1.52,1.14,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 80 MG CHEW,277,CDM,250,RC,904579146,NDC,,,facility,both,5.625,UN,,1.3,0.98,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TABS,27719,CDM,250,RC,904714004,NDC,,,facility,both,0.5,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TABS,27719,CDM,250,RC,53746071101,NDC,,,facility,both,2,UN,,5.02,3.77,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TABS,27719,CDM,250,RC,65162071110,NDC,,,facility,both,0.5,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TABS,27719,CDM,250,RC,904714004,NDC,,,facility,both,2,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TABS,27719,CDM,250,RC,65162071110,NDC,,,facility,both,2,UN,,4.78,3.58,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TABS,27719,CDM,250,RC,53746071101,NDC,,,facility,both,0.5,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TABS,27719,CDM,250,RC,904714004,NDC,,,facility,both,1,UN,,11.15,8.36,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TABS,27719,CDM,250,RC,65162071110,NDC,,,facility,both,1,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG TABS,27719,CDM,250,RC,53746071101,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 50 MG/ML SOLN,27737,CDM,636,RC,J1631,HCPCS,67457041013,NDC,facility,both,50,ME,,54.8,41.1,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 50 MG/ML SOLN,27737,CDM,636,RC,J1631,HCPCS,70069003001,NDC,facility,both,50,ME,,83.38,62.54,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG TABS,2776,CDM,250,RC,69315013601,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG TABS,2776,CDM,250,RC,68084038101,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG TABS,2776,CDM,250,RC,69315013601,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG TABS,2776,CDM,250,RC,69315013601,NDC,,,facility,both,4,UN,,2.12,1.59,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1644,HCPCS,63739093128,NDC,facility,both,1000,UN,,9.33,7,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1644,HCPCS,71288040210,NDC,facility,both,1000,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1644,HCPCS,67457038599,NDC,facility,both,1000,UN,,5.46,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1644,HCPCS,69004301,NDC,facility,both,1000,UN,,3.91,2.93,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1644,HCPCS,409272001,NDC,facility,both,1000,UN,,28.68,21.51,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1644,HCPCS,409272002,NDC,facility,both,1000,UN,,4.91,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,both,1000,UN,,2.04,1.53,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1643,HCPCS,69005801,NDC,facility,both,1000,UN,,4.91,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1644,HCPCS,63323054015,NDC,facility,both,1000,UN,,3.69,2.77,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN,27762,CDM,636,RC,J1644,HCPCS,641039112,NDC,facility,both,1000,UN,,13.8,10.35,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN 1 ML VIAL,27762,CDM,636,RC,J1644,HCPCS,641039112,NDC,facility,both,1000,UN,,31.9,23.92,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN 1 ML VIAL,27762,CDM,636,RC,J1644,HCPCS,409272001,NDC,facility,both,1000,UN,,26.15,19.61,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1000 UNITS/ML SOLN 10 ML VIAL,27762,CDM,636,RC,J1644,HCPCS,63323054015,NDC,facility,both,1000,UN,,8.28,6.21,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG TABS,2777,CDM,250,RC,68084038811,NDC,,,facility,both,0.5,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG TABS,2777,CDM,250,RC,69315013701,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG TABS,2777,CDM,250,RC,68084038811,NDC,,,facility,both,2,UN,,4.75,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG TABS,2777,CDM,250,RC,69315013701,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG TABS,2777,CDM,250,RC,68084038811,NDC,,,facility,both,1,UN,,8.46,6.35,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 5000 UNITS/ML SOLN,27770,CDM,636,RC,J1644,HCPCS,409272301,NDC,facility,both,1000,UN,,7.88,5.91,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 5000 UNITS/ML SOLN,27770,CDM,636,RC,J1644,HCPCS,63323026206,NDC,facility,both,1000,UN,,6.3,4.73,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 5000 UNITS/ML SOLN,27770,CDM,636,RC,J1644,HCPCS,641040012,NDC,facility,both,1000,UN,,8.49,6.36,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 5000 UNITS/ML SOLN,27770,CDM,636,RC,J1644,HCPCS,409272330,NDC,facility,both,1000,UN,,7.89,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 5000 UNITS/ML SOLN 1 ML VIAL,27770,CDM,636,RC,J1644,HCPCS,641040012,NDC,facility,both,1000,UN,,8.64,6.48,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VACCINE DIALYSIS FORMULATION 40 MCG/ML SUSP,27778,CDM,636,RC,90740,HCPCS,6499200,NDC,facility,both,1,ML,,222.45,166.84,,,,,,,,,,Gross Charge Type: Pharmacy
Noncdm Charge Record Medical Supplies,27800000S1_270,CDM,270,RC,,,,,facility,both,,,,119.82,89.86,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_272,CDM,272,RC,,,,,facility,both,,,,110.34,82.76,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_278,CDM,278,RC,,,,,facility,both,,,,531.9,398.92,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_A4264_278,CDM,278,RC,A4264,HCPCS,,,facility,both,,,,346.5,259.88,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_A4648_278,CDM,278,RC,A4648,HCPCS,,,facility,both,,,,89.42,67.06,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_A4649_278,CDM,278,RC,A4649,HCPCS,,,facility,both,,,,1100.84,825.63,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_B4087_278,CDM,278,RC,B4087,HCPCS,,,facility,both,,,,409.18,306.88,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1713_278,CDM,278,RC,C1713,HCPCS,,,facility,both,,,,940.23,705.17,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1714_272,CDM,272,RC,C1714,HCPCS,,,facility,both,,,,8911.88,6683.91,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1714_278,CDM,278,RC,C1714,HCPCS,,,facility,both,,,,8911.88,6683.91,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1724_278,CDM,278,RC,C1724,HCPCS,,,facility,both,,,,4948.12,3711.09,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1725_272,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,330.75,248.06,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1725_278,CDM,278,RC,C1725,HCPCS,,,facility,both,,,,593.91,445.43,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1726_272,CDM,272,RC,C1726,HCPCS,,,facility,both,,,,607.82,455.86,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1726_278,CDM,278,RC,C1726,HCPCS,,,facility,both,,,,1368.6,1026.45,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1727_278,CDM,278,RC,C1727,HCPCS,,,facility,both,,,,2866.5,2149.88,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1729_278,CDM,278,RC,C1729,HCPCS,,,facility,both,,,,438.42,328.82,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1730_278,CDM,278,RC,C1730,HCPCS,,,facility,both,,,,3032.48,2274.36,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1732_278,CDM,278,RC,C1732,HCPCS,,,facility,both,,,,6630.67,4973,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1733_278,CDM,278,RC,C1733,HCPCS,,,facility,both,,,,5205.3,3903.98,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1734_278,CDM,278,RC,C1734,HCPCS,,,facility,both,,,,9017.91,6763.43,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1747_278,CDM,278,RC,C1747,HCPCS,,,facility,both,,,,614.25,460.69,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1748_272,CDM,272,RC,C1748,HCPCS,,,facility,both,,,,7691.25,5768.44,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1748_278,CDM,278,RC,C1748,HCPCS,,,facility,both,,,,7736.23,5802.17,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1750_278,CDM,278,RC,C1750,HCPCS,,,facility,both,,,,793.31,594.98,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1751_278,CDM,278,RC,C1751,HCPCS,,,facility,both,,,,514.66,386,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1752_278,CDM,278,RC,C1752,HCPCS,,,facility,both,,,,649.63,487.22,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1753_278,CDM,278,RC,C1753,HCPCS,,,facility,both,,,,527.91,395.93,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1755_278,CDM,278,RC,C1755,HCPCS,,,facility,both,,,,2250.45,1687.84,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1756_278,CDM,278,RC,C1756,HCPCS,,,facility,both,,,,338.49,253.87,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1757_272,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,11568.38,8676.28,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1757_278,CDM,278,RC,C1757,HCPCS,,,facility,both,,,,7890.38,5917.78,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1758_278,CDM,278,RC,C1758,HCPCS,,,facility,both,,,,106.99,80.24,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1759_278,CDM,278,RC,C1759,HCPCS,,,facility,both,,,,5298.32,3973.74,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1760_278,CDM,278,RC,C1760,HCPCS,,,facility,both,,,,777.1,582.82,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1761_272,CDM,272,RC,C1761,HCPCS,,,facility,both,,,,12337.5,9253.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1761_278,CDM,278,RC,C1761,HCPCS,,,facility,both,,,,12337.5,9253.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1762_278,CDM,278,RC,C1762,HCPCS,,,facility,both,,,,5856.07,4392.05,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1763_278,CDM,278,RC,C1763,HCPCS,,,facility,both,,,,2194.64,1645.98,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1764_278,CDM,278,RC,C1764,HCPCS,,,facility,both,,,,14585.05,10938.79,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1765_278,CDM,278,RC,C1765,HCPCS,,,facility,both,,,,1134.45,850.84,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1766_278,CDM,278,RC,C1766,HCPCS,,,facility,both,,,,219.74,164.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1767_278,CDM,278,RC,C1767,HCPCS,,,facility,both,,,,69530.31,52147.73,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1768_278,CDM,278,RC,C1768,HCPCS,,,facility,both,,,,3906.49,2929.87,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1769_270,CDM,270,RC,C1769,HCPCS,,,facility,both,,,,190.91,143.18,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1769_272,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,883.75,662.81,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1769_278,CDM,278,RC,C1769,HCPCS,,,facility,both,,,,747.89,560.92,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1771_278,CDM,278,RC,C1771,HCPCS,,,facility,both,,,,5061.44,3796.08,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1772_278,CDM,278,RC,C1772,HCPCS,,,facility,both,,,,26514.84,19886.13,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1773_278,CDM,278,RC,C1773,HCPCS,,,facility,both,,,,1033.99,775.49,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1776_278,CDM,278,RC,C1776,HCPCS,,,facility,both,,,,7178.18,5383.64,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1777_278,CDM,278,RC,C1777,HCPCS,,,facility,both,,,,9417.46,7063.1,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1778_278,CDM,278,RC,C1778,HCPCS,,,facility,both,,,,10304.79,7728.59,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1781_278,CDM,278,RC,C1781,HCPCS,,,facility,both,,,,1331.6,998.7,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1783_278,CDM,278,RC,C1783,HCPCS,,,facility,both,,,,199.49,149.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1787_278,CDM,278,RC,C1787,HCPCS,,,facility,both,,,,4439.48,3329.61,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1788_278,CDM,278,RC,C1788,HCPCS,,,facility,both,,,,1258.11,943.58,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1789_278,CDM,278,RC,C1789,HCPCS,,,facility,both,,,,1398.9,1049.18,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1813_278,CDM,278,RC,C1813,HCPCS,,,facility,both,,,,20204.02,15153.02,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1815_278,CDM,278,RC,C1815,HCPCS,,,facility,both,,,,10193.14,7644.86,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1817_278,CDM,278,RC,C1817,HCPCS,,,facility,both,,,,19133.26,14349.94,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1819_278,CDM,278,RC,C1819,HCPCS,,,facility,both,,,,113.16,84.87,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1820_278,CDM,278,RC,C1820,HCPCS,,,facility,both,,,,51513,38634.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1822_278,CDM,278,RC,C1822,HCPCS,,,facility,both,,,,60470.55,45352.91,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1831_278,CDM,278,RC,C1831,HCPCS,,,facility,both,,,,73710,55282.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1874_278,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,5834.96,4376.22,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1875_278,CDM,278,RC,C1875,HCPCS,,,facility,both,,,,11452.92,8589.69,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1876_270,CDM,270,RC,C1876,HCPCS,,,facility,both,,,,289.61,217.21,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1876_278,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,2331.02,1748.26,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1878_278,CDM,278,RC,C1878,HCPCS,,,facility,both,,,,2142,1606.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1880_278,CDM,278,RC,C1880,HCPCS,,,facility,both,,,,5100.38,3825.28,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1883_278,CDM,278,RC,C1883,HCPCS,,,facility,both,,,,2594,1945.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1884_272,CDM,272,RC,C1884,HCPCS,,,facility,both,,,,3150,2362.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1884_278,CDM,278,RC,C1884,HCPCS,,,facility,both,,,,4227.39,3170.54,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1886_278,CDM,278,RC,C1886,HCPCS,,,facility,both,,,,6475.88,4856.91,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1887_270,CDM,270,RC,C1887,HCPCS,,,facility,both,,,,448.15,336.11,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1887_272,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,871.5,653.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1887_278,CDM,278,RC,C1887,HCPCS,,,facility,both,,,,481.34,361,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1888_272,CDM,272,RC,C1888,HCPCS,,,facility,both,,,,2756.25,2067.19,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1888_278,CDM,278,RC,C1888,HCPCS,,,facility,both,,,,2756.25,2067.19,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1889_270,CDM,270,RC,C1889,HCPCS,,,facility,both,,,,768.16,576.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1889_272,CDM,272,RC,C1889,HCPCS,,,facility,both,,,,614.21,460.66,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1889_278,CDM,278,RC,C1889,HCPCS,,,facility,both,,,,2913.41,2185.06,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1892_272,CDM,272,RC,C1892,HCPCS,,,facility,both,,,,49.14,36.86,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1892_278,CDM,278,RC,C1892,HCPCS,,,facility,both,,,,80.33,60.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1893_278,CDM,278,RC,C1893,HCPCS,,,facility,both,,,,541.92,406.44,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1894_270,CDM,270,RC,C1894,HCPCS,,,facility,both,,,,417.5,313.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1894_272,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,991.25,743.44,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1894_278,CDM,278,RC,C1894,HCPCS,,,facility,both,,,,301.33,226,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1895_278,CDM,278,RC,C1895,HCPCS,,,facility,both,,,,9591.75,7193.81,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1897_278,CDM,278,RC,C1897,HCPCS,,,facility,both,,,,425.25,318.94,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1898_278,CDM,278,RC,C1898,HCPCS,,,facility,both,,,,1266.38,949.78,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C1900_278,CDM,278,RC,C1900,HCPCS,,,facility,both,,,,4970.02,3727.52,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2615_278,CDM,278,RC,C2615,HCPCS,,,facility,both,,,,2703.75,2027.81,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2616_278,CDM,278,RC,C2616,HCPCS,,,facility,both,,,,47458.21,35593.66,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2617_270,CDM,270,RC,C2617,HCPCS,,,facility,both,,,,289.61,217.21,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2617_278,CDM,278,RC,C2617,HCPCS,,,facility,both,,,,244.58,183.44,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2621_278,CDM,278,RC,C2621,HCPCS,,,facility,both,,,,14494.2,10870.65,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2623_272,CDM,272,RC,C2623,HCPCS,,,facility,both,,,,3885,2913.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2623_278,CDM,278,RC,C2623,HCPCS,,,facility,both,,,,4458.02,3343.52,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2624_278,CDM,278,RC,C2624,HCPCS,,,facility,both,,,,61674.38,46255.78,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2625_278,CDM,278,RC,C2625,HCPCS,,,facility,both,,,,538.49,403.87,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2628_278,CDM,278,RC,C2628,HCPCS,,,facility,both,,,,1499.17,1124.38,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2629_278,CDM,278,RC,C2629,HCPCS,,,facility,both,,,,323.4,242.55,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2630_278,CDM,278,RC,C2630,HCPCS,,,facility,both,,,,9693.89,7270.42,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C2631_278,CDM,278,RC,C2631,HCPCS,,,facility,both,,,,1447.82,1085.86,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C9352_278,CDM,278,RC,C9352,HCPCS,,,facility,both,,,,6141.08,4605.81,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_C9353_278,CDM,278,RC,C9353,HCPCS,,,facility,both,,,,6614.38,4960.78,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_L8600_278,CDM,278,RC,L8600,HCPCS,,,facility,both,,,,2047.5,1535.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_L8606_278,CDM,278,RC,L8606,HCPCS,,,facility,both,,,,3501.75,2626.31,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_L8613_278,CDM,278,RC,L8613,HCPCS,,,facility,both,,,,25.55,19.16,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_L8699_278,CDM,278,RC,L8699,HCPCS,,,facility,both,,,,48564.21,36423.16,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_Q4104_278,CDM,278,RC,Q4104,HCPCS,,,facility,both,,,,10430.77,7823.08,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_Q4116_278,CDM,278,RC,Q4116,HCPCS,,,facility,both,,,,8538.18,6403.64,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_Q4118_278,CDM,278,RC,Q4118,HCPCS,,,facility,both,,,,771.12,578.34,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_Q4125_278,CDM,278,RC,Q4125,HCPCS,,,facility,both,,,,9579.95,7184.96,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_Q4130_278,CDM,278,RC,Q4130,HCPCS,,,facility,both,,,,4250.82,3188.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,27800000S1_Q4166_278,CDM,278,RC,Q4166,HCPCS,,,facility,both,,,,234.28,175.71,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
HYDROXYCHLOROQUINE 200 MG TABS,27893,CDM,250,RC,68084026901,NDC,,,facility,both,1.5,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG TABS,27893,CDM,250,RC,68084026901,NDC,,,facility,both,0.5,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG TABS,27893,CDM,250,RC,68084026901,NDC,,,facility,both,1,UN,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG TABS,27893,CDM,250,RC,63739077710,NDC,,,facility,both,1,UN,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG TABS,27893,CDM,250,RC,68084026901,NDC,,,facility,both,2,UN,,7.82,5.87,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG TABS,27893,CDM,250,RC,63739077710,NDC,,,facility,both,1.5,UN,,6.88,5.16,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA 500 MG CAPS,27895,CDM,250,RC,68084028401,NDC,,,facility,both,2,UN,,25.88,19.41,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA 500 MG CAPS,27895,CDM,250,RC,68084028401,NDC,,,facility,both,4,UN,,17.11,12.83,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA 500 MG CAPS,27895,CDM,250,RC,68084028401,NDC,,,facility,both,3,UN,,20.03,15.02,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA 500 MG CAPS,27895,CDM,250,RC,68084028401,NDC,,,facility,both,1,UN,,43.4,32.55,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5ML SUSP,27912,CDM,250,RC,MHS1ML,HCPCS,68094049462,NDC,facility,both,5,ML,,3.27,2.45,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5ML SUSP,27912,CDM,250,RC,MHS1ML,HCPCS,68094060061,NDC,facility,both,5,ML,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5ML SUSP,27912,CDM,250,RC,MHS1ML,HCPCS,121091400,NDC,facility,both,5,ML,,3.06,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
IFOSFAMIDE SOLR 1 EACH VIAL,27920,CDM,636,RC,J9208,HCPCS,10019092602,NDC,facility,both,1,GM,,104.91,78.69,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH 100 UNITS/ML SUSP,27981,CDM,637,RC,J1815,HCPCS,169183411,NDC,facility,both,5,UN,,6.5,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH 100 UNITS/ML SUSP,27981,CDM,636,RC,J1815,HCPCS,169183411,NDC,facility,both,5,UN,,6.68,5.01,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN 70/30 100 UNITS/ML SUSP,27988,CDM,636,RC,J1815,HCPCS,169183711,NDC,facility,both,5,UN,,4.89,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN 70/30 100 UNITS/ML SUSP,27988,CDM,637,RC,J1815,HCPCS,169183711,NDC,facility,both,5,UN,,4.74,3.55,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS/ML SOLN,27993,CDM,636,RC,J1815,HCPCS,169183311,NDC,facility,both,5,UN,,15.08,11.31,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR (HUMAN) 100 UNITS/ML SOLN,27993,CDM,637,RC,J1815,HCPCS,169183311,NDC,facility,both,5,UN,,15.95,11.96,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 2 MG/ML SYRP,27997,CDM,250,RC,MHS1MG,HCPCS,904711341,NDC,facility,both,1,ME,,1.84,1.38,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 2 MG/ML SYRP,27997,CDM,250,RC,MHS1MG,HCPCS,68094076462,NDC,facility,both,1,ME,,1.67,1.25,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 350 MG/ML SOLN,28058,CDM,636,RC,Q9967,HCPCS,407141491,NDC,facility,both,1,ML,,3.07,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 350 MG/ML SOLN,28058,CDM,636,RC,Q9967,HCPCS,407141493,NDC,facility,both,1,ML,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % SOLN,28060,CDM,636,RC,Q9966,HCPCS,270141111,NDC,facility,both,1,ML,,5.47,4.1,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % SOLN,28062,CDM,255,RC,Q9967,HCPCS,270141215,NDC,facility,both,1,ML,,6.67,5,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % SOLN,28062,CDM,636,RC,Q9967,HCPCS,270141215,NDC,facility,both,1,ML,,4.91,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % SOLN,28063,CDM,255,RC,Q9967,HCPCS,270131604,NDC,facility,both,1,ML,,0.66,0.49,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % SOLN,28063,CDM,255,RC,Q9967,HCPCS,270131635,NDC,facility,both,1,ML,,0.78,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % SOLN,28063,CDM,636,RC,Q9967,HCPCS,270131604,NDC,facility,both,1,ML,,0.65,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % SOLN,28063,CDM,636,RC,Q9967,HCPCS,270131635,NDC,facility,both,1,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % SOLN,28063,CDM,636,RC,Q9967,HCPCS,270131645,NDC,facility,both,1,ML,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % SOLN,28063,CDM,636,RC,Q9967,HCPCS,270131637,NDC,facility,both,1,ML,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
IOTHALAMATE MEGLUMINE 17.2 % SOLN,28066,CDM,636,RC,Q9958,HCPCS,19086250,NDC,facility,both,1,ML,,0.23,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
IOTHALAMATE MEGLUMINE 17.2 % SOLN,28066,CDM,255,RC,Q9958,HCPCS,19086250,NDC,facility,both,1,ML,,0.23,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
IOTHALAMATE MEGLUMINE 60 % SOLN,28070,CDM,636,RC,Q9961,HCPCS,19095305,NDC,facility,both,1,ML,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
IOTHALAMATE MEGLUMINE 60 % SOLN,28070,CDM,255,RC,Q9961,HCPCS,19095305,NDC,facility,both,1,ML,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 10 MG TABS,28152,CDM,250,RC,228263111,NDC,,,facility,both,2,UN,,3.92,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 10 MG TABS,28152,CDM,250,RC,228263111,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 10 MG TABS,28152,CDM,250,RC,228263111,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 20 MG TABS,28153,CDM,250,RC,228262011,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 20 MG TABS,28153,CDM,250,RC,228262011,NDC,,,facility,both,1.5,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 20 MG TABS,28153,CDM,250,RC,228262011,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
ISRADIPINE 2.5 MG CAPS,28164,CDM,250,RC,42806026301,NDC,,,facility,both,2,UN,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
ITRACONAZOLE 100 MG CAPS,28167,CDM,250,RC,60687029925,NDC,,,facility,both,2,UN,,9.48,7.11,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM DI & MONO PHOSPHATE-SODIUM PHOSPHATE ELEMENTAL PHOSPHORUS 250 MG TABS,28169,CDM,250,RC,64980010401,NDC,,,facility,both,2,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM DI & MONO PHOSPHATE-SODIUM PHOSPHATE ELEMENTAL PHOSPHORUS 250 MG TABS,28169,CDM,250,RC,64980010401,NDC,,,facility,both,1,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
KETOCONAZOLE 200 MG TABS,28197,CDM,250,RC,35573043330,NDC,,,facility,both,2,UN,,5.5,4.12,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5ML SOLN,282,CDM,250,RC,MHS1ML,HCPCS,81033000230,NDC,facility,both,1,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5ML SOLN,282,CDM,250,RC,MHS1ML,HCPCS,68094023161,NDC,facility,both,1,ML,,1.2,0.9,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 60 MG TB24,28208,CDM,250,RC,13668010501,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 60 MG TB24,28208,CDM,250,RC,904645061,NDC,,,facility,both,0.5,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 60 MG TB24,28208,CDM,250,RC,13668010501,NDC,,,facility,both,1,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 60 MG TB24,28208,CDM,250,RC,904645061,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 60 MG TB24,28208,CDM,250,RC,904645061,NDC,,,facility,both,3,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 60 MG TB24,28208,CDM,250,RC,13668010501,NDC,,,facility,both,1.5,UN,,3.78,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 60 MG TB24,28208,CDM,250,RC,904645061,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 60 MG TB24,28208,CDM,250,RC,904645061,NDC,,,facility,both,1.5,UN,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 10 MG TABS,28216,CDM,250,RC,93031401,NDC,,,facility,both,1,UN,,9.65,7.24,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 10 MG TABS,28216,CDM,250,RC,60687010421,NDC,,,facility,both,1,UN,,18.8,14.1,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 10 MG TABS,28216,CDM,250,RC,93031401,NDC,,,facility,both,2,UN,,5.8,4.35,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 10 MG TABS,28216,CDM,250,RC,60687010421,NDC,,,facility,both,2,UN,,14.22,10.67,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC 10 MG TABS,28216,CDM,250,RC,70710171001,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,250,RC,MHS1ML,HCPCS,143962201,NDC,facility,both,5,ME,,3.39,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,636,RC,J1921,HCPCS,143962201,NDC,facility,both,5,ME,,3.39,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,250,RC,J1921,HCPCS,143962201,NDC,facility,both,5,ME,,3.39,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,250,RC,MHS1ML,HCPCS,72611073401,NDC,facility,both,5,ME,,16.45,12.34,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,250,RC,MHS1ML,HCPCS,72572035001,NDC,facility,both,5,ME,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,636,RC,J1920,HCPCS,72603014601,NDC,facility,both,5,ME,,10.83,8.12,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,250,RC,J1920,HCPCS,72611073401,NDC,facility,both,5,ME,,16.45,12.34,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,250,RC,J1920,HCPCS,72572035001,NDC,facility,both,5,ME,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,636,RC,J1920,HCPCS,72266010201,NDC,facility,both,5,ME,,10.88,8.16,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,636,RC,J1920,HCPCS,72611073401,NDC,facility,both,5,ME,,12.71,9.53,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN,28223,CDM,636,RC,J1920,HCPCS,72572035001,NDC,facility,both,5,ME,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML SOLN 20 ML VIAL,28223,CDM,636,RC,J1921,HCPCS,143962201,NDC,facility,both,5,ME,,1.39,1.04,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG TABS,28224,CDM,250,RC,23155072301,NDC,,,facility,both,1,UN,,7.37,5.53,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG TABS,28224,CDM,250,RC,23155072301,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG TABS,28225,CDM,250,RC,60687045011,NDC,,,facility,both,2,UN,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG TABS,28225,CDM,250,RC,60687045011,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG TABS,28225,CDM,250,RC,904592961,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
AMMONIUM LACTATE 12 % LOTN 225 G BOTTLE,28236,CDM,250,RC,MHS1GM,HCPCS,45802041954,NDC,facility,both,1,GM,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
AMMONIUM LACTATE 12 % LOTN 226 G BOTTLE,28236,CDM,250,RC,MHS1GM,HCPCS,904598426,NDC,facility,both,1,GM,,0.19,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
AMMONIUM LACTATE 12 % LOTN 227 G BOTTLE,28236,CDM,250,RC,MHS1GM,HCPCS,45802052555,NDC,facility,both,1,GM,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 7.5 MG KIT,28260,CDM,636,RC,J9217,HCPCS,74364203,NDC,facility,both,7.5,ME,,6068.75,4551.56,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 88 MCG TABS,28280,CDM,250,RC,42292003820,NDC,,,facility,both,0.5,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 88 MCG TABS,28280,CDM,250,RC,42292003820,NDC,,,facility,both,1,UN,,8.74,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 88 MCG TABS,28280,CDM,250,RC,42292003820,NDC,,,facility,both,1.5,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG TABS,28281,CDM,250,RC,378181177,NDC,,,facility,both,1,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG TABS,28281,CDM,250,RC,904695461,NDC,,,facility,both,1.2232,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG TABS,28281,CDM,250,RC,904695461,NDC,,,facility,both,2,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG TABS,28281,CDM,250,RC,42292003920,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG TABS,28281,CDM,250,RC,904695461,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG TABS,28281,CDM,250,RC,904695461,NDC,,,facility,both,0.7768,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG TABS,28281,CDM,250,RC,60687050811,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 137 MCG TABS,28282,CDM,250,RC,42292004120,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG TABS,28283,CDM,250,RC,42292004020,NDC,,,facility,both,0.497142857,UN,,8.3,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG TABS,28283,CDM,250,RC,42292004020,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG TABS,28283,CDM,250,RC,60687054101,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG TABS,28283,CDM,250,RC,42292004020,NDC,,,facility,both,0.9943,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,4,UN,,2.9,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,904677361,NDC,,,facility,both,3.076923077,UN,,1.72,1.29,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,FAMRXNC,HCPCS,49348097310,NDC,facility,both,2,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,904677361,NDC,,,facility,both,3,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,536132710,NDC,,,facility,both,1,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,1.5,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,904677361,NDC,,,facility,both,1,UN,,4.51,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,1,UN,,8.53,6.39,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,3.076923077,UN,,2.66,2,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,FAMRXNC,HCPCS,904677361,NDC,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,63739008702,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,904677361,NDC,,,facility,both,1.076923077,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,1.538461539,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,904677361,NDC,,,facility,both,2,UN,,3.3,2.47,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,57896010201,NDC,,,facility,both,3.076923077,UN,,1.58,1.18,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,1.076923077,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,2,UN,,4.8,3.6,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,57896010201,NDC,,,facility,both,2,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,0.4615,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,1.2308,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,49348097310,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,57896010201,NDC,,,facility,both,1,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,49348097310,NDC,,,facility,both,2,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,FAMRXNC,HCPCS,904677361,NDC,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,3,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,536132710,NDC,,,facility,both,2,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,FAMRXNC,HCPCS,49348097310,NDC,facility,both,3,UN,,2.17,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,904677361,NDC,,,facility,both,4,UN,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,50580045811,NDC,,,facility,both,2.7692,UN,,3.47,2.6,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG TABS,283,CDM,250,RC,63739008702,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,FAMRXNC,HCPCS,63323048257,NDC,facility,both,1,ME,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,FAMRXNC,HCPCS,409317802,NDC,facility,both,1,ME,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,J3490,HCPCS,409317801,NDC,facility,both,1,ME,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,FAMRXNC,HCPCS,63323048217,NDC,facility,both,1,ME,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,MHS1ML,HCPCS,409317801,NDC,facility,both,1,ME,,2.04,1.53,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,J3490,HCPCS,409317802,NDC,facility,both,1,ME,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,MHS1ML,HCPCS,63323048227,NDC,facility,both,1,ME,,2.22,1.67,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,MHS1ML,HCPCS,409317802,NDC,facility,both,1,ME,,1.5,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,FAMRXNC,HCPCS,409317801,NDC,facility,both,1,ME,,2.11,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE 1 % W/ EPI 1:100,000 1 % SOLN",28324,CDM,250,RC,FAMRXNC,HCPCS,63323048227,NDC,facility,both,1,ME,,1.61,1.2,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % W/ EPI (PRES FREE) 1 % SOLN,28325,CDM,250,RC,FAMRXNC,HCPCS,63323048737,NDC,facility,both,1,ME,,2.31,1.73,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % W/ EPI (PRES FREE) 1 % SOLN,28325,CDM,250,RC,MHS10ML,HCPCS,63323048737,NDC,facility,both,1,ME,,33.07,24.8,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % W/ EPI 2 %-1:100000 SOLN,28327,CDM,250,RC,MHS1ML,HCPCS,409318201,NDC,facility,both,1,ME,,1.8,1.35,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % W/ EPI 2 %-1:100000 SOLN,28327,CDM,250,RC,FAMRXNC,HCPCS,63323048327,NDC,facility,both,1,ME,,1.63,1.22,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % W/ EPI 2 %-1:100000 SOLN,28327,CDM,250,RC,MHS1ML,HCPCS,63323048327,NDC,facility,both,1,ME,,2.26,1.7,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-PRILOCAINE 2.5-2.5 % CREA 30 G TUBE,28333,CDM,250,RC,MHS1GM,HCPCS,168035730,NDC,facility,both,1,GM,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-PRILOCAINE 2.5-2.5 % CREA 30 G TUBE,28333,CDM,250,RC,MHS1GM,HCPCS,62332058231,NDC,facility,both,1,GM,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-PRILOCAINE 2.5-2.5 % CREA 5 G TUBE,28333,CDM,250,RC,MHS1GM,HCPCS,62332058204,NDC,facility,both,1,GM,,10.27,7.7,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-PRILOCAINE 2.5-2.5 % CREA 5 G TUBE,28333,CDM,250,RC,MHS1GM,HCPCS,168035755,NDC,facility,both,1,GM,,9.83,7.37,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE SODIUM 10 MCG/ML SOLN,28353,CDM,250,RC,39822015101,NDC,,,facility,both,1,ML,,1043,782.25,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,51862032001,NDC,,,facility,both,1,UN,,9.84,7.38,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,51862032001,NDC,,,facility,both,0.5,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,51862032001,NDC,,,facility,both,2,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,51862032001,NDC,,,facility,both,1.5,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,51862032001,NDC,,,facility,both,4,UN,,4.06,3.05,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,42794001812,NDC,,,facility,both,0.5,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,42794001812,NDC,,,facility,both,2,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,42794001812,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,42794001812,NDC,,,facility,both,4,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,42794001812,NDC,,,facility,both,2.5,UN,,3.78,2.84,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 5 MCG TABS,28354,CDM,250,RC,51862032001,NDC,,,facility,both,2.5,UN,,4.42,3.31,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,68180098001,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,43547035310,NDC,,,facility,both,4,UN,,1.66,1.25,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,904679861,NDC,,,facility,both,0.5,UN,,6.17,4.63,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,43547035310,NDC,,,facility,both,0.5,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,904679861,NDC,,,facility,both,1,UN,,6.34,4.75,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,68180098001,NDC,,,facility,both,4,UN,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,68180098001,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,43547035310,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,904679861,NDC,,,facility,both,1.5,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,43547035310,NDC,,,facility,both,2,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,68180098001,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,904679861,NDC,,,facility,both,2,UN,,3.33,2.5,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,904679861,NDC,,,facility,both,3,UN,,2.33,1.75,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG TABS,28360,CDM,250,RC,904679861,NDC,,,facility,both,4,UN,,1.84,1.38,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 5 MG TABS,28362,CDM,250,RC,904679761,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 5 MG TABS,28362,CDM,250,RC,904679761,NDC,,,facility,both,4,UN,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 5 MG TABS,28362,CDM,250,RC,904679761,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 5 MG TABS,28362,CDM,250,RC,904679761,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MG TABS,28363,CDM,250,RC,68180051901,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MG TABS,28363,CDM,250,RC,68180051901,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MG TABS,28363,CDM,250,RC,68180051901,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL-HYDROCHLOROTHIAZIDE 20-25 MG TABS,28364,CDM,250,RC,68180052001,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL-HYDROCHLOROTHIAZIDE 20-25 MG TABS,28364,CDM,250,RC,68180052001,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL-HYDROCHLOROTHIAZIDE 20-25 MG TABS,28364,CDM,250,RC,68180052002,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL-HYDROCHLOROTHIAZIDE 20-25 MG TABS,28364,CDM,250,RC,68180052001,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TBCR,28365,CDM,250,RC,51079018020,NDC,,,facility,both,4,UN,,2.65,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TBCR,28365,CDM,250,RC,51079018020,NDC,,,facility,both,1,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TBCR,28365,CDM,250,RC,68462022301,NDC,,,facility,both,4,UN,,2.29,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TBCR,28365,CDM,250,RC,68462022301,NDC,,,facility,both,2,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TBCR,28365,CDM,250,RC,51079018020,NDC,,,facility,both,2,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 300 MG TBCR,28365,CDM,250,RC,51079018020,NDC,,,facility,both,3,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 450 MG TBCR,28366,CDM,250,RC,68084065501,NDC,,,facility,both,4,UN,,2.86,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 450 MG TBCR,28366,CDM,250,RC,68084065501,NDC,,,facility,both,2,UN,,4.69,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 450 MG TBCR,28366,CDM,250,RC,68084065501,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 450 MG TBCR,28366,CDM,250,RC,51079014220,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM 450 MG TBCR,28366,CDM,250,RC,51079014220,NDC,,,facility,both,2,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG TABS,28385,CDM,250,RC,FAMRXNC,HCPCS,904685261,NDC,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG TABS,28385,CDM,250,RC,68084024801,NDC,,,facility,both,1,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG TABS,28385,CDM,250,RC,68084024801,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG TABS,28385,CDM,250,RC,68084024801,NDC,,,facility,both,2,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG TABS,28385,CDM,250,RC,FAMRXNC,HCPCS,68084024801,NDC,facility,both,1,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG TABS,28385,CDM,250,RC,904685261,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML SOLN,28387,CDM,636,RC,J2060,HCPCS,641604425,NDC,facility,both,2,ME,,31.23,23.42,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML SOLN,28387,CDM,636,RC,J2060,HCPCS,641600125,NDC,facility,both,2,ME,,33.52,25.14,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML SOLN,28387,CDM,636,RC,J2060,HCPCS,641604825,NDC,facility,both,2,ME,,30.11,22.58,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML SOLN,28387,CDM,636,RC,J2060,HCPCS,409198530,NDC,facility,both,2,ME,,35.28,26.46,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML SOLN 10 ML VIAL,28387,CDM,636,RC,J2060,HCPCS,641604610,NDC,facility,both,2,ME,,1.73,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,63739028110,NDC,,,facility,both,2,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,68180046801,NDC,,,facility,both,4,UN,,1.81,1.36,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,68180046801,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,68180046801,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,68180046801,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,68180046807,NDC,,,facility,both,2,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,68180046807,NDC,,,facility,both,1,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,68180046807,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,63739028110,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG TABS,28393,CDM,250,RC,68180046801,NDC,,,facility,both,1.5,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904673061,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,57896022110,NDC,,,facility,both,1,UN,,6.02,4.52,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,FAMRXNC,HCPCS,904673061,NDC,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904673061,NDC,,,facility,both,1.3,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,57896022110,NDC,,,facility,both,2,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,50580045711,NDC,,,facility,both,0.7,UN,,1.1,0.82,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,FAMRXNC,HCPCS,904672040,NDC,facility,both,2,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,FAMRXNC,HCPCS,904673061,NDC,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904673061,NDC,,,facility,both,0.65,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904672040,NDC,,,facility,both,2,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904673061,NDC,,,facility,both,3,UN,,2.22,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,50580045711,NDC,,,facility,both,1.3,UN,,4.02,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,50580045711,NDC,,,facility,both,0.5,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904673061,NDC,,,facility,both,0.5,UN,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904673061,NDC,,,facility,both,0.7,UN,,4.15,3.11,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904672040,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,50580045711,NDC,,,facility,both,1,UN,,7.47,5.6,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904673061,NDC,,,facility,both,1.5,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,904673061,NDC,,,facility,both,1,UN,,6.23,4.68,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 500 MG TABS,284,CDM,250,RC,50580045711,NDC,,,facility,both,2,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
LYSINE HCL 500 MG TABS,28407,CDM,250,RC,30768000830,NDC,,,facility,both,1,UN,,8.3,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
LYSINE HCL 500 MG TABS,28407,CDM,250,RC,30768000830,NDC,,,facility,both,2,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG TABS,28414,CDM,250,RC,68382047230,NDC,,,facility,both,0.5,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG TABS,28414,CDM,250,RC,68382047230,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG TABS,28414,CDM,250,RC,62332008830,NDC,,,facility,both,1,UN,,10.2,7.65,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG TABS,28414,CDM,250,RC,597004037,NDC,,,facility,both,1,UN,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG TABS,28414,CDM,250,RC,62332008830,NDC,,,facility,both,0.5,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG TABS,28414,CDM,250,RC,68382047230,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 80 MG TABS,28415,CDM,250,RC,68382047330,NDC,,,facility,both,0.5,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 80 MG TABS,28415,CDM,250,RC,597004137,NDC,,,facility,both,1,UN,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 80 MG TABS,28415,CDM,250,RC,68382047330,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,28443,CDM,250,RC,64980033901,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG TABS,28533,CDM,250,RC,54458111,NDC,,,facility,both,1.5,UN,,32.4,24.3,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 250 MG CPCR,28538,CDM,250,RC,54092018981,NDC,,,facility,both,4,UN,,7.41,5.56,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN-HYDROCHLOROTHIAZIDE 100-25 MG TABS,28542,CDM,250,RC,65862047030,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN-HYDROCHLOROTHIAZIDE 100-25 MG TABS,28542,CDM,250,RC,68180021706,NDC,,,facility,both,1,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN-HYDROCHLOROTHIAZIDE 100-25 MG TABS,28542,CDM,250,RC,68180021709,NDC,,,facility,both,0.5,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN-HYDROCHLOROTHIAZIDE 100-25 MG TABS,28542,CDM,250,RC,68180021709,NDC,,,facility,both,1,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 4 G ENEM,28543,CDM,250,RC,MHS60ML,HCPCS,45802009851,NDC,facility,both,60,ML,,38.4,28.8,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML SOLN 10 ML VIAL,28547,CDM,636,RC,J9209,HCPCS,338130501,NDC,facility,both,200,ME,,10.81,8.11,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TABS,28557,CDM,250,RC,65862000801,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TABS,28557,CDM,250,RC,60687015501,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TABS,28557,CDM,250,RC,904716261,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TABS,28557,CDM,250,RC,65862000801,NDC,,,facility,both,2,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TABS,28557,CDM,250,RC,67877056101,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TABS,28557,CDM,250,RC,60687015501,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TABS,28557,CDM,250,RC,904716261,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TABS,28557,CDM,250,RC,60687015501,NDC,,,facility,both,2,UN,,3.82,2.87,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TABS,28557,CDM,250,RC,904716261,NDC,,,facility,both,1,UN,,6.39,4.79,,,,,,,,,,Gross Charge Type: Pharmacy
METHENAMINE 1 G TABS,28577,CDM,250,RC,65862078201,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 1000 MG TABS,28581,CDM,250,RC,904716461,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 1000 MG TABS,28581,CDM,250,RC,904716461,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 1000 MG TABS,28581,CDM,250,RC,904716461,NDC,,,facility,both,2,UN,,3.62,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG TABS,28593,CDM,250,RC,23155007101,NDC,,,facility,both,0.5,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG TABS,28593,CDM,250,RC,51293082101,NDC,,,facility,both,1.5,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG TABS,28593,CDM,250,RC,51293082101,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG TABS,28593,CDM,250,RC,23155007101,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG TABS,28593,CDM,250,RC,23155007101,NDC,,,facility,both,3,UN,,3.03,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG TABS,28593,CDM,250,RC,51293082101,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG TABS,28593,CDM,250,RC,23155007101,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 5 MG TABS,28594,CDM,250,RC,23155007001,NDC,,,facility,both,1.5,UN,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 5 MG TABS,28594,CDM,250,RC,23155007001,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 5 MG TABS,28594,CDM,250,RC,23155007001,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 120 MG SUPP,286,CDM,250,RC,MHS1EA,HCPCS,45802073230,NDC,facility,both,1,EA,,17.85,13.39,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE DEPOT FORMULATION 10 MG KIT,28639,CDM,636,RC,J2353,HCPCS,78079061,NDC,facility,both,1,ME,,763.33,572.5,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE DEPOT FORMULATION 20 MG KIT,28642,CDM,636,RC,J2353,HCPCS,78081881,NDC,facility,both,1,ME,,499.93,374.95,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE DEPOT FORMULATION 30 MG KIT,28643,CDM,636,RC,J2353,HCPCS,78082581,NDC,facility,both,1,ME,,499.64,374.73,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML SOLN,28647,CDM,636,RC,J2210,HCPCS,51991014417,NDC,facility,both,0.2,ME,,100.15,75.11,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG TABS,28648,CDM,250,RC,27437005057,NDC,,,facility,both,1,UN,,107.15,80.36,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG TABS,28648,CDM,250,RC,69238160502,NDC,,,facility,both,1,UN,,39.6,29.7,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUCCINATE SOLR 1 EACH VIAL,28658,CDM,636,RC,J2930,HCPCS,9001820,NDC,facility,both,5,ME,,24.41,18.3,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUCCINATE 62.5MG/ML SOLR 1 EACH VIAL,28662,CDM,636,RC,J2919,HCPCS,9075801,NDC,facility,both,5,ME,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUCCINATE SOLR 1 EACH VIAL,28662,CDM,636,RC,J2930,HCPCS,9075801,NDC,facility,both,5,ME,,26.69,20.02,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUCCINATE SOLR 1 EACH VIAL,28662,CDM,636,RC,J2919,HCPCS,9000302,NDC,facility,both,5,ME,,1.69,1.27,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 2.5 MG TABS,28683,CDM,250,RC,51079002320,NDC,,,facility,both,1,UN,,13.3,9.98,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 2.5 MG TABS,28683,CDM,250,RC,51079002320,NDC,,,facility,both,2,UN,,8.98,6.73,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 5 MG TABS,28684,CDM,250,RC,51079002420,NDC,,,facility,both,1,UN,,14.05,10.54,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 5 MG TABS,28684,CDM,250,RC,51079002420,NDC,,,facility,both,0.5,UN,,11,8.25,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 5 MG TABS,28684,CDM,250,RC,51079002420,NDC,,,facility,both,2,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML SOLN,28705,CDM,250,RC,MHS1ML,HCPCS,54312041,NDC,facility,both,1,ML,,12.42,9.32,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 0.75 % GEL 70 G TUBE,28709,CDM,250,RC,MHS1GM,HCPCS,781707787,NDC,facility,both,1,GM,,2.34,1.76,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 0.75 % GEL 70 G TUBE,28709,CDM,250,RC,MHS1GM,HCPCS,245086070,NDC,facility,both,1,GM,,1.75,1.31,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 150 MG CAPS,28725,CDM,250,RC,93873901,NDC,,,facility,both,1,UN,,10.5,7.88,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 200 MG CAPS,28726,CDM,250,RC,62559082101,NDC,,,facility,both,1,UN,,9.95,7.46,,,,,,,,,,Gross Charge Type: Pharmacy
MICONAZOLE 200 MG SUPP,28746,CDM,250,RC,472173803,NDC,,,facility,both,1,UN,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
MICROFIBRILLAR COLLAGEN POWD,28751,CDM,250,RC,53276101002,NDC,,,facility,both,1,GR,,356.15,267.11,,,,,,,,,,Gross Charge Type: Pharmacy
MICROFIBRILLAR COLLAGEN POWD 1 G JAR,28751,CDM,250,RC,53276101002,NDC,,,facility,both,1,GR,,356.15,267.11,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 5 MG/ML SOLN,28753,CDM,636,RC,J2250,HCPCS,409230801,NDC,facility,both,1,ME,,9.14,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 5 MG/ML SOLN,28753,CDM,636,RC,J2250,HCPCS,641606125,NDC,facility,both,1,ME,,25.16,18.87,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG TABS,28788,CDM,250,RC,60687074611,NDC,,,facility,both,2,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG TABS,28788,CDM,250,RC,59762500801,NDC,,,facility,both,2,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG TABS,28788,CDM,250,RC,59762500801,NDC,,,facility,both,4,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG TABS,28788,CDM,250,RC,59762500801,NDC,,,facility,both,3,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG TABS,28788,CDM,250,RC,59762500801,NDC,,,facility,both,1,UN,,6.82,5.11,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG TABS,28788,CDM,250,RC,60687074601,NDC,,,facility,both,3,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG TABS,28788,CDM,250,RC,59762500801,NDC,,,facility,both,5,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG TABS,28788,CDM,250,RC,60687074611,NDC,,,facility,both,3,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG TABS,28788,CDM,250,RC,60687074601,NDC,,,facility,both,2,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN SOLR 1 EACH VIAL,28789,CDM,636,RC,J9280,HCPCS,65219056620,NDC,facility,both,5,ME,,121.26,90.94,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN SOLR 1 EACH VIAL,28789,CDM,636,RC,J9280,HCPCS,71288013850,NDC,facility,both,5,ME,,494.33,370.75,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN SOLR 1 EACH VIAL,28789,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,both,5,ME,,98.88,74.16,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN SOLR 1 EACH VIAL,28791,CDM,636,RC,J9280,HCPCS,16729011505,NDC,facility,both,5,ME,,825.93,619.45,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 325 MG SUPP,288,CDM,250,RC,MHS1EA,HCPCS,51672211602,NDC,facility,both,1,EA,,15.82,11.87,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % OINT 15 G TUBE,28883,CDM,250,RC,MHS1GM,HCPCS,51672131201,NDC,facility,both,1,GM,,3.51,2.63,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % OINT 22 G TUBE,28883,CDM,250,RC,MHS1GM,HCPCS,68462018022,NDC,facility,both,1,GM,,2.17,1.63,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % OINT 22 G TUBE,28883,CDM,250,RC,MHS1GM,HCPCS,45802011222,NDC,facility,both,1,GM,,2.19,1.64,,,,,,,,,,Gross Charge Type: Pharmacy
NABUMETONE 500 MG TABS,28886,CDM,250,RC,76282025701,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
NABUMETONE 500 MG TABS,28886,CDM,250,RC,50228046501,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
NABUMETONE 500 MG TABS,28886,CDM,250,RC,60687063011,NDC,,,facility,both,1,UN,,10.65,7.99,,,,,,,,,,Gross Charge Type: Pharmacy
NABUMETONE 750 MG TABS,28887,CDM,250,RC,50228046601,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG CAPS,28891,CDM,250,RC,904650261,NDC,,,facility,both,2,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG CAPS,28891,CDM,250,RC,50268016815,NDC,,,facility,both,1,UN,,10.05,7.54,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG CAPS,28891,CDM,250,RC,904650261,NDC,,,facility,both,1,UN,,10.3,7.72,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG CAPS,28891,CDM,250,RC,50268016815,NDC,,,facility,both,2,UN,,6.18,4.63,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG CAPS,28893,CDM,250,RC,904650361,NDC,,,facility,both,1,UN,,11.1,8.32,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG CAPS,28893,CDM,250,RC,904650361,NDC,,,facility,both,2,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG SUPP,289,CDM,250,RC,MHS1EA,HCPCS,45802073030,NDC,facility,both,1,EA,,20.85,15.64,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG TABS,28902,CDM,250,RC,68084029121,NDC,,,facility,both,2,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG TABS,28902,CDM,250,RC,904703604,NDC,,,facility,both,1,UN,,11.5,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG TABS,28902,CDM,250,RC,68084029121,NDC,,,facility,both,1,UN,,12.2,9.15,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG TABS,28902,CDM,250,RC,68084029121,NDC,,,facility,both,0.5,UN,,10,7.5,,,,,,,,,,Gross Charge Type: Pharmacy
BETHANECHOL 10 MG TABS,2891,CDM,250,RC,832051101,NDC,,,facility,both,4,UN,,2.71,2.03,,,,,,,,,,Gross Charge Type: Pharmacy
BETHANECHOL 10 MG TABS,2891,CDM,250,RC,832051101,NDC,,,facility,both,1,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
BETHANECHOL 10 MG TABS,2891,CDM,250,RC,832051101,NDC,,,facility,both,2,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 40,000 UNITS/ML SOLN 1 ML VIAL",28918,CDM,636,RC,J0885,HCPCS,59676034001,NDC,facility,both,1000,UN,,34.62,25.97,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA 40,000 UNITS/ML SOLN 1 ML VIAL",28918,CDM,636,RC,Q4081,HCPCS,59676034001,NDC,facility,both,1000,UN,,3.46,2.6,,,,,,,,,,Gross Charge Type: Pharmacy
BETHANECHOL 25 MG TABS,2892,CDM,250,RC,832051201,NDC,,,facility,both,0.5,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
BETHANECHOL 25 MG TABS,2892,CDM,250,RC,832051201,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 30 MG TB24,28926,CDM,250,RC,904644961,NDC,,,facility,both,3,UN,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 30 MG TB24,28926,CDM,250,RC,904644961,NDC,,,facility,both,0.5,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 30 MG TB24,28926,CDM,250,RC,904644961,NDC,,,facility,both,2,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 30 MG TB24,28926,CDM,250,RC,904644961,NDC,,,facility,both,4,UN,,2.74,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 30 MG TB24,28926,CDM,250,RC,904644961,NDC,,,facility,both,1,UN,,8.27,6.2,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 30 MG TB24,28926,CDM,250,RC,50742017501,NDC,,,facility,both,2,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 30 MG TB24,28926,CDM,250,RC,50742017501,NDC,,,facility,both,1,UN,,6.56,4.92,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL 0.5 % SOLG 5 ML BOTTLE,29009,CDM,250,RC,MHS1ml,HCPCS,61314022505,NDC,facility,both,1,ML,,56.08,42.06,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL 0.5 % SOLG 5 ML BOTTLE,29009,CDM,250,RC,MHS1ml,HCPCS,62332054605,NDC,facility,both,1,ML,,54.89,41.17,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG GUM,29071,CDM,250,RC,49348069136,NDC,,,facility,both,1,UN,,3.85,2.89,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG GUM,29071,CDM,250,RC,70677008501,NDC,,,facility,both,1,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG GUM,29071,CDM,250,RC,536302923,NDC,,,facility,both,2,UN,,2.22,1.67,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG GUM,29071,CDM,250,RC,536302923,NDC,,,facility,both,1,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG GUM,29072,CDM,250,RC,49348057236,NDC,,,facility,both,0.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG GUM,29072,CDM,250,RC,49348057208,NDC,,,facility,both,1,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG GUM,29072,CDM,250,RC,49348057236,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG GUM,29072,CDM,250,RC,49348069236,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
NIMODIPINE 30 MG CAPS,29094,CDM,250,RC,23155051200,NDC,,,facility,both,2,UN,,6.38,4.78,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN 25 MG/5ML SUSP,29101,CDM,250,RC,MHS5ML,HCPCS,70408023932,NDC,facility,both,5,ML,,61.28,45.96,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN MONOHYDRATE MACROCRYSTALS 100 MG CAPS,29104,CDM,250,RC,185012201,NDC,,,facility,both,1,UN,,11.05,8.29,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN MONOHYDRATE MACROCRYSTALS 100 MG CAPS,29104,CDM,250,RC,60687063301,NDC,,,facility,both,1,UN,,12.21,9.15,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL 0.4-35 MG-MCG TABS,29146,CDM,250,RC,68462031684,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG TABS,29159,CDM,250,RC,68462030450,NDC,,,facility,both,2,UN,,5.98,4.49,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG TABS,29159,CDM,250,RC,68462030450,NDC,,,facility,both,1,UN,,9.81,7.36,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG TABS,29159,CDM,250,RC,68462030450,NDC,,,facility,both,6,UN,,3.16,2.37,,,,,,,,,,Gross Charge Type: Pharmacy
NORGESTIMATE-ETHINYL ESTRADIOL 0.25-35 MG-MCG TABS,29168,CDM,250,RC,16714036004,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
NORGESTIMATE-ETHINYL ESTRADIOL 0.25-35 MG-MCG TABS,29168,CDM,250,RC,68462030984,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
NORGESTIMATE-ETHINYL ESTRADIOL 0.18/0.215/0.25 MG-35 MCG TABS,29169,CDM,250,RC,16714036301,NDC,,,facility,both,1,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
NORGESTIMATE-ETHINYL ESTRADIOL 0.18/0.215/0.25 MG-35 MCG TABS,29169,CDM,250,RC,16714036304,NDC,,,facility,both,1,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG TABS,29225,CDM,250,RC,65862018830,NDC,,,facility,both,0.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG TABS,29225,CDM,250,RC,65862018830,NDC,,,facility,both,1,UN,,7.25,5.43,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN-NEOMYCIN-POLYMYXIN 3.5-400-5000 OINT,29291,CDM,250,RC,MHS1GM,HCPCS,45802014370,NDC,facility,both,1,GM,,25.6,19.2,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCHLOROSENE POWD 2 G BOX,29294,CDM,250,RC,327000110,NDC,,,facility,both,3,GR,,25.25,18.94,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCHLOROSENE POWD 2 G BOX,29294,CDM,250,RC,327000110,NDC,,,facility,both,2,GR,,46.05,34.54,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 100 MG/5ML CONC,29295,CDM,250,RC,406855730,NDC,,,facility,both,1.5,ML,,10.8,8.1,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 100 MG/5ML CONC,29295,CDM,250,RC,406855730,NDC,,,facility,both,0.25,ML,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 100 MG/5ML CONC,29295,CDM,250,RC,406855730,NDC,,,facility,both,1,ML,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 100 MG/5ML CONC,29295,CDM,250,RC,406855730,NDC,,,facility,both,0.5,ML,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 100 MG/5ML CONC,29295,CDM,250,RC,406855730,NDC,,,facility,both,0.75,ML,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5ML SOLN,29296,CDM,250,RC,MHS1ML,HCPCS,121482740,NDC,facility,both,1,ML,,3.06,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,10702001801,NDC,,,facility,both,1,UN,,5.22,3.91,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,10702001850,NDC,,,facility,both,2,UN,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,406055262,NDC,,,facility,both,6,UN,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000110,NDC,,,facility,both,4,UN,,1.77,1.33,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000110,NDC,,,facility,both,12,UN,,0.9,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000110,NDC,,,facility,both,1.6,UN,,2.98,2.23,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000101,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000110,NDC,,,facility,both,1.5,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,10702001801,NDC,,,facility,both,1.5,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,68084035401,NDC,,,facility,both,1,UN,,6.04,4.53,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,406055262,NDC,,,facility,both,0.5,UN,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,904696661,NDC,,,facility,both,1,UN,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,406055262,NDC,,,facility,both,3,UN,,2.67,2,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000101,NDC,,,facility,both,3,UN,,1.87,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,68084035401,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,406055262,NDC,,,facility,both,1,UN,,6.1,4.57,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,68084035401,NDC,,,facility,both,4,UN,,2.22,1.67,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,10702001850,NDC,,,facility,both,1,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,10702001850,NDC,,,facility,both,3,UN,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,68084035401,NDC,,,facility,both,6,UN,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,68084035401,NDC,,,facility,both,3,UN,,2.67,2,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000110,NDC,,,facility,both,2,UN,,3.07,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,406055262,NDC,,,facility,both,5,UN,,1.97,1.48,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000101,NDC,,,facility,both,2,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000110,NDC,,,facility,both,3,UN,,2.2,1.65,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,10702001801,NDC,,,facility,both,0.5,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000101,NDC,,,facility,both,4,UN,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,406055262,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,10702001801,NDC,,,facility,both,3,UN,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,904696661,NDC,,,facility,both,2,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000110,NDC,,,facility,both,6,UN,,1.34,1.01,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,406055262,NDC,,,facility,both,1.5,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000110,NDC,,,facility,both,0.5,UN,,5.43,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000101,NDC,,,facility,both,1.5,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,406055262,NDC,,,facility,both,4,UN,,2.22,1.67,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000101,NDC,,,facility,both,6,UN,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,10702001801,NDC,,,facility,both,2,UN,,2.76,2.07,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000110,NDC,,,facility,both,1,UN,,5.63,4.22,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,42858000101,NDC,,,facility,both,1,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG TABS,29298,CDM,250,RC,10702001850,NDC,,,facility,both,6,UN,,1.04,0.78,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG TABS,29304,CDM,250,RC,68084062121,NDC,,,facility,both,2,UN,,23.98,17.98,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG TABS,29304,CDM,250,RC,68084062121,NDC,,,facility,both,1,UN,,27.05,20.29,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG TABS,29304,CDM,250,RC,65862060130,NDC,,,facility,both,4,UN,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG TABS,29304,CDM,250,RC,65862060130,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG TABS,29304,CDM,250,RC,65862060130,NDC,,,facility,both,2,UN,,3.82,2.87,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,904567761,NDC,,,facility,both,1,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,68084004501,NDC,,,facility,both,4,UN,,2.61,1.96,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,68084004501,NDC,,,facility,both,2.25,UN,,3.07,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,904567761,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,68084004501,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,68084004501,NDC,,,facility,both,2.5,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,68084004501,NDC,,,facility,both,1,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,904567761,NDC,,,facility,both,1.25,UN,,1,0.75,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,68084004501,NDC,,,facility,both,3,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS,29473,CDM,250,RC,68084004501,NDC,,,facility,both,1.5,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TABS 100 EACH BOX,29473,CDM,250,RC,904567761,NDC,,,facility,both,2,UN,,0.62,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,60687038701,NDC,,,facility,both,2,UN,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,245021111,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,60687038701,NDC,,,facility,both,4,UN,,3.34,2.5,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,60687038701,NDC,,,facility,both,3,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,904681706,NDC,,,facility,both,2,UN,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,904681706,NDC,,,facility,both,4,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,60687038701,NDC,,,facility,both,1,UN,,8.87,6.65,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,60687038701,NDC,,,facility,both,6,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,904681706,NDC,,,facility,both,1,UN,,8.52,6.39,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,904681706,NDC,,,facility,both,3,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,245021111,NDC,,,facility,both,4,UN,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,904681706,NDC,,,facility,both,6,UN,,2.48,1.86,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,245021111,NDC,,,facility,both,6,UN,,2.17,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,245021111,NDC,,,facility,both,3,UN,,3.47,2.6,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 2.5 MG TABS,296,CDM,250,RC,245021111,NDC,,,facility,both,1,UN,,6.94,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
PERMETHRIN 5 % CREA 60 G TUBE,29625,CDM,250,RC,MHS1GM,HCPCS,472024260,NDC,facility,both,1,GM,,3.14,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
PERMETHRIN 1 % LIQD,29626,CDM,250,RC,63736012002,NDC,,,facility,both,59,ML,,73.25,54.94,,,,,,,,,,Gross Charge Type: Pharmacy
PERMETHRIN 1 % LIQD,29626,CDM,250,RC,63736012003,NDC,,,facility,both,59,ML,,50.45,37.84,,,,,,,,,,Gross Charge Type: Pharmacy
PHENELZINE 15 MG TABS,29648,CDM,250,RC,59762011901,NDC,,,facility,both,3,UN,,3.98,2.99,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE SOLR,29729,CDM,636,RC,J2760,HCPCS,143956410,NDC,facility,both,5,ME,,2540.01,1905.01,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE SOLR 1 EACH VIAL,29729,CDM,636,RC,J2760,HCPCS,143956410,NDC,facility,both,5,ME,,1065.05,798.79,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.125 MG SUBL,29733,CDM,250,RC,42192033901,NDC,,,facility,both,2.6,UN,,2.98,2.24,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.125 MG SUBL,29733,CDM,250,RC,42192033901,NDC,,,facility,both,1,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.125 MG SUBL,29733,CDM,250,RC,42192033901,NDC,,,facility,both,3,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.125 MG SUBL,29733,CDM,250,RC,42192033901,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG CP24,29740,CDM,250,RC,591288201,NDC,,,facility,both,2,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG CP24,29740,CDM,250,RC,591288201,NDC,,,facility,both,1,UN,,10.8,8.1,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 240 MG CP24,29741,CDM,250,RC,591288401,NDC,,,facility,both,1,UN,,11.15,8.36,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 50 MG TABS,29761,CDM,250,RC,93206506,NDC,,,facility,both,2,UN,,3.95,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 50 MG TABS,29761,CDM,250,RC,93206506,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 100 MG TABS,29763,CDM,250,RC,50268017715,NDC,,,facility,both,0.5,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 100 MG TABS,29763,CDM,250,RC,50268017715,NDC,,,facility,both,1,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 100 MG TABS,29763,CDM,250,RC,93206406,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 100 MG TABS,29763,CDM,250,RC,93206406,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.125 % SOLN 15 ML BOTTLE,29792,CDM,250,RC,MHS1ML,HCPCS,56184012105,NDC,facility,both,1,ML,,0.82,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG CAPS,29862,CDM,636,RC,J7507,HCPCS,68084044901,NDC,facility,both,1,ME,,9.19,6.9,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG CAPS,29862,CDM,636,RC,J7507,HCPCS,904662361,NDC,facility,both,1,ME,,8.71,6.53,,,,,,,,,,Gross Charge Type: Pharmacy
LEVALBUTEROL 1.25 MG/3ML NEBU,29866,CDM,250,RC,MHS1ML,HCPCS,76204090001,NDC,facility,both,1,ML,,4.59,3.44,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC GLUCONATE COMPLEX 12.5 MG/ML SOLN 5 ML VIAL,29887,CDM,636,RC,J2916,HCPCS,143957010,NDC,facility,both,12.5,ME,,7.04,5.28,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG CHEW,29945,CDM,250,RC,60687015625,NDC,,,facility,both,4,UN,,4.8,3.6,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG CHEW,29945,CDM,250,RC,60687015625,NDC,,,facility,both,6,UN,,4.04,3.03,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG CHEW,29945,CDM,250,RC,60687015625,NDC,,,facility,both,2,UN,,6.92,5.19,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG CHEW,29945,CDM,250,RC,60687015625,NDC,,,facility,both,1,UN,,10.9,8.18,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG CHEW,29945,CDM,250,RC,51672414601,NDC,,,facility,both,2,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 30 MG CAPS,29948,CDM,250,RC,71374066,NDC,,,facility,both,1,UN,,10.35,7.76,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 30 MG CAPS,29948,CDM,250,RC,71374066,NDC,,,facility,both,4,UN,,4.36,3.27,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 30 MG CAPS,29948,CDM,250,RC,71374066,NDC,,,facility,both,5,UN,,3.92,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 17 GM/SCOOP POWD,29996,CDM,250,RC,MHS1GM,HCPCS,45802086801,NDC,facility,both,1,GM,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 17 GM/SCOOP POWD 119 G BOTTLE,29996,CDM,250,RC,MHS1GM,HCPCS,41100082076,NDC,facility,both,1,GM,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
Miscellaneous Lab (Ref Lab),3000000001,CDM,300,RC,,,,,facility,both,,,,0.01,0.01,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Jak2 Exon 12 Mutation Analys,B (Ref Lab)",3000027U01,CDM,300,RC,0027U,HCPCS,,,facility,both,,,,436,327,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Jak2 Exon 12 Mutation Analys,B (Ref Lab)",3000027U01,CDM,300,RC,0027U,HCPCS,,,facility,both,,,,436,327,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Pvjak-  Jak2  Gene Analysis, Targeted Sequence Analysis Exons 12-15",3000027U02,CDM,300,RC,0027U,HCPCS,,,facility,both,,,,436,327,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Thiopurine Methyltransferase (Tpmt) And Nudix Hydrolase (Nudt15), (Ref Lab)",3000034U01,CDM,300,RC,0034U,HCPCS,,,facility,both,,,,590,442.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Thiopurine Methyltransferase (Tpmt) And Nudix Hydrolase (Nudt15), (Ref Lab)",3000034U01,CDM,300,RC,0034U,HCPCS,,,facility,both,,,,493,369.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc C Neuro (Prion Disease),Cerebrospinal Fluid,Detec Prion Protein By Quakg Confirm,Qualitative (Ref",3000035U01,CDM,300,RC,0035U,HCPCS,,,facility,both,,,,787,590.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arup: Neurology (Prion Disease), Cerebrospinal Fluid, Detection Of Prion Protein By Quaking-Induc",3000035U02,CDM,300,RC,0035U,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arup: Neurology (Prion Disease), Cerebrospinal Fluid, Detection Of Prion Protein By Quaking-Induc",3000035U02,CDM,300,RC,0035U,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Foundationone Cdx (Ref Lab),3000037U01,CDM,300,RC,0037U,HCPCS,,,facility,both,,,,4428,3321,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyp2D6 Genotype Cascade (Ref Lab),3000070U01,CDM,300,RC,0070U,HCPCS,,,facility,both,,,,856,642,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyp2D6 Genotype Cascade (Ref Lab),3000070U01,CDM,300,RC,0070U,HCPCS,,,facility,both,,,,690,517.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Peiso Ig Paraprotein Qual Bld/Ur,3000077U01,CDM,300,RC,0077U,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Peiso Ig Paraprotein Qual Bld/Ur,3000077U01,CDM,300,RC,0077U,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dmoga Ig Paraprotein Qual Bld/Ur,3000077U02,CDM,300,RC,0077U,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dmoga Ig Paraprotein Qual Bld/Ur,3000077U02,CDM,300,RC,0077U,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Mptru-M-Protein Mass-Fix, Random, Urine",3000077U03,CDM,300,RC,0077U,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mptru-M-Protein Mass-Fix, Random, Urine",3000077U03,CDM,300,RC,0077U,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Qmpss-Ig Paraprotein Qual Imprcip&Ms Bld/Ur W/Isotype,3000077U04,CDM,300,RC,0077U,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Qmpss-Ig Paraprotein Qual Imprcip&Ms Bld/Ur W/Isotype,3000077U04,CDM,300,RC,0077U,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Respiratory Panel Pcr,3000115U01,CDM,300,RC,0115U,HCPCS,,,facility,both,,,,727,545.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Respiratory Panel Pcr,3000115U01,CDM,300,RC,0115U,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Blood Culture Id Gram Posi Pnl,3000141U01,CDM,300,RC,0141U,HCPCS,,,facility,both,,,,1548,1161,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Blood Culture Id Gram Posi Pnl,3000141U01,CDM,300,RC,0141U,HCPCS,,,facility,both,,,,460,345,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Blood Culture Id Gram Posi Pnl,3000141U01,CDM,300,RC,0141U,HCPCS,,,facility,both,,,,400,300,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Blood Culture Id Gram Neg Pnl,3000142U01,CDM,300,RC,0142U,HCPCS,,,facility,both,,,,1624,1218,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Blood Culture Id Gram Neg Pnl,3000142U01,CDM,300,RC,0142U,HCPCS,,,facility,both,,,,460,345,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Blood Culture Id Gram Neg Pnl,3000142U01,CDM,300,RC,0142U,HCPCS,,,facility,both,,,,400,300,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc C Infectious Disease,Dna,Pcr And Next Generation Seq Plasma,Det Of Over 1,000 Potential Micro Org",3000152U01,CDM,300,RC,0152U,HCPCS,,,facility,both,,,,2924,2193,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Zw300-Cell-Free Dna Sequencing Of Disease-Causing Organisms In Plasma Specimen, With Report",3000152U02,CDM,300,RC,0152U,HCPCS,,,facility,both,,,,2543,1907.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Zw300-Cell-Free Dna Sequencing Of Disease-Causing Organisms In Plasma Specimen, With Report",3000152U02,CDM,300,RC,0152U,HCPCS,,,facility,both,,,,2543,1907.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Respiratory Pathogen Panel, Pcr, Nasopharyngeal (Ref Lab)",3000202U01,CDM,300,RC,0202U,HCPCS,,,facility,both,,,,538,403.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Respiratory Pathogen Panel, Pcr, Nasopharyngeal (Ref Lab)",3000202U01,CDM,300,RC,0202U,HCPCS,,,facility,both,,,,538,403.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Amyr-Neuro Mld Cog Impairmnt Alys ??-Amyloid 1-42&1-40,3000358U01,CDM,300,RC,0358U,HCPCS,,,facility,both,,,,886,664.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Malp-Malabsorption Evaluation Panel,3000430U01,CDM,300,RC,0430U,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Malp-Malabsorption Evaluation Panel,3000430U01,CDM,300,RC,0430U,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Glycs-Glycine Receptor Alpha1 Igg, Serum Or Cerebrospinal Fluid (Csf), Live Cell-Binding Ass",3000431U01,CDM,300,RC,0431U,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Glycs-Glycine Receptor Alpha1 Igg, Serum Or Cerebrospinal Fluid (Csf), Live Cell-Binding Ass",3000431U01,CDM,300,RC,0431U,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Mds2-Kelch-Like Protein 11 (Klhl11) Antibody, Serum Or Cerebrospinal Fluid (Csf), Cell-Bindi",3000432U01,CDM,300,RC,0432U,HCPCS,,,facility,both,,,,0.03,0.02,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mds2-Kelch-Like Protein 11 (Klhl11) Antibody, Serum Or Cerebrospinal Fluid (Csf), Cell-Bindi",3000432U01,CDM,300,RC,0432U,HCPCS,,,facility,both,,,,0.03,0.02,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
DANTROLENE 5 MG/ML 5 MG/ML,3001018,CDM,250,RC,115441101,NDC,,,facility,both,28,ML,,9.72,7.29,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA 100 MG/ML 100 MG/ML,3001029,CDM,250,RC,68084028401,NDC,,,facility,both,5,ML,,123.39,92.54,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA 100 MG/ML 100 MG/ML,3001029,CDM,250,RC,68084028401,NDC,,,facility,both,10,ML,,121.41,91.06,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML 1 MG/ML,3001048,CDM,250,RC,43598040516,NDC,,,facility,both,2.5,ML,,29.9,22.42,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML 1 MG/ML,3001048,CDM,250,RC,43598040516,NDC,,,facility,both,10,ML,,94.4,70.8,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML 1 MG/ML,3001048,CDM,250,RC,43598040516,NDC,,,facility,both,1,ML,,16.05,12.04,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML 1 MG/ML,3001048,CDM,250,RC,43598040516,NDC,,,facility,both,5,ML,,51.7,38.78,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML 1 MG/ML,3001048,CDM,250,RC,43598040516,NDC,,,facility,both,0.5,ML,,11,8.25,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE MOFETIL 200 MG/ML SUSR,30023,CDM,636,RC,J7517,HCPCS,67877023022,NDC,facility,both,250,ME,,19.88,14.91,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL POLYSACCHARIDE VACCINE 25 MCG/0.5ML INJ,30040,CDM,636,RC,90732,HCPCS,6483703,NDC,facility,both,0.5,ML,,150.12,112.59,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ,30040,CDM,6483701,NDC,,,,,facility,both,0.5,ML,,145.44,109.08,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ,30040,CDM,6483703,NDC,,,,,facility,both,0.5,ML,,145.44,109.08,,,,,,,,,,Gross Charge Type: Pharmacy
POLYCARBOPHIL 625 MG TABS,30059,CDM,250,RC,77333012025,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
POLYCARBOPHIL 625 MG TABS,30059,CDM,250,RC,77333012025,NDC,,,facility,both,2,UN,,5.02,3.77,,,,,,,,,,Gross Charge Type: Pharmacy
POLYCARBOPHIL 625 MG TABS,30059,CDM,250,RC,536430608,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
POLYCARBOPHIL 625 MG TABS,30059,CDM,250,RC,77333011810,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
POLYCARBOPHIL 625 MG TABS,30059,CDM,250,RC,77333012025,NDC,,,facility,both,0.5,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
POLYCARBOPHIL 625 MG TABS,30059,CDM,250,RC,536430608,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
POLYCARBOPHIL 625 MG TABS,30059,CDM,250,RC,77333011810,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
IRON POLYSACCHARIDES 150 MG CAPS,30070,CDM,250,RC,51991020311,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Kh Non Mayo-General Health Panel,3008005001,CDM,300,RC,80050,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non Mayo-General Health Panel,3008005001,CDM,300,RC,80050,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Acetaminophen,3008014301,CDM,300,RC,80143,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Acetaminophen,3008014301,CDM,300,RC,80143,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Drug Screen Quantitative Alcohol, Urine",3008032001,CDM,300,RC,80320,HCPCS,,,facility,both,,,,217,162.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Drug Screen Quantitative Alcohol, Urine",3008032001,CDM,300,RC,80320,HCPCS,,,facility,both,,,,217,162.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Csmeu- Drug Screen Quant Amphetamines 5 Or More,3008032601,CDM,300,RC,80326,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmeu- Drug Screen Quant Amphetamines 5 Or More,3008032601,CDM,300,RC,80326,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Csmpu - Drug Screen Quant Amphetamines 5 Or More,3008032602,CDM,300,RC,80326,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmpu - Drug Screen Quant Amphetamines 5 Or More,3008032602,CDM,300,RC,80326,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Csmtu-Drug Screen Quant Amphetamines 5 Or More,3008032603,CDM,300,RC,80326,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmtu-Drug Screen Quant Amphetamines 5 Or More,3008032603,CDM,300,RC,80326,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Tspu-Drug Screen Quant Amphetamines 5 Or More,3008032604,CDM,300,RC,80326,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Tspu-Drug Screen Quant Amphetamines 5 Or More,3008032604,CDM,300,RC,80326,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Famcs-Drug Screen Quant Amphetamines 5 Or More,3008032605,CDM,300,RC,80326,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Famcs-Drug Screen Quant Amphetamines 5 Or More,3008032605,CDM,300,RC,80326,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Csmeu- Drug Screening Benzodiazepines 13 Or More,3008034702,CDM,300,RC,80347,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmeu- Drug Screening Benzodiazepines 13 Or More,3008034702,CDM,300,RC,80347,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fbcs-Drug Screening Benzodiazepines 13 Or More,3008034703,CDM,300,RC,80347,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmpu - Drug Screening Benzodiazepines 13 Or More,3008034704,CDM,300,RC,80347,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmpu - Drug Screening Benzodiazepines 13 Or More,3008034704,CDM,300,RC,80347,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Csmtu-Drug Screening Benzodiazepines 13 Or More,3008034705,CDM,300,RC,80347,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmtu-Drug Screening Benzodiazepines 13 Or More,3008034705,CDM,300,RC,80347,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Tbsu-Drug Screening Benzodiazepines 13 Or More,3008034706,CDM,300,RC,80347,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Tbsu-Drug Screening Benzodiazepines 13 Or More,3008034706,CDM,300,RC,80347,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fentanyl Screen W/Reflex Confirmation,3008035404,CDM,300,RC,80354,HCPCS,,,facility,both,,,,217,162.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fentanyl Screen W/Reflex Confirmation,3008035404,CDM,300,RC,80354,HCPCS,,,facility,both,,,,217,162.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fhmtb-Hydrocodone And Mtb, Free",3008036101,CDM,300,RC,80361,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fhmtb-Hydrocodone And Mtb, Free",3008036101,CDM,300,RC,80361,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drugscan: Drug Screening Opiates 1 Or More,3008036102,CDM,300,RC,80361,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan: Drug Screening Opiates 1 Or More,3008036102,CDM,300,RC,80361,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Drugscan: Morphine Confirmation, Add'l",3008036103,CDM,300,RC,80361,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Drugscan: Morphine Confirmation, Add'l",3008036103,CDM,300,RC,80361,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Csmeu-Csm Enhanced Profile,21, Hrms/Ia, Urine",3008036401,CDM,300,RC,80364,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Csmeu-Csm Enhanced Profile,21, Hrms/Ia, Urine",3008036401,CDM,300,RC,80364,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Csmpu - Opioids And Opiate Analogs; 5 Or More,3008036402,CDM,300,RC,80364,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmpu - Opioids And Opiate Analogs; 5 Or More,3008036402,CDM,300,RC,80364,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Csmtu-Drug Screening Opioids & Opiate Analogs 5/More,3008036403,CDM,300,RC,80364,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmtu-Drug Screening Opioids & Opiate Analogs 5/More,3008036403,CDM,300,RC,80364,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Tram-Tramadol And Metabolite, Urine",3008037302,CDM,300,RC,80373,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Tram-Tramadol And Metabolite, Urine",3008037302,CDM,300,RC,80373,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Hypog-Hypoglycemic Agent Screen, Serum",3008037701,CDM,300,RC,80377,HCPCS,,,facility,both,,,,133,99.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Hypog-Hypoglycemic Agent Screen, Serum",3008037701,CDM,300,RC,80377,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fslfu-Sulfonylurea Screen, Qt, Urine",3008037702,CDM,300,RC,80377,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fslfu-Sulfonylurea Screen, Qt, Urine",3008037702,CDM,300,RC,80377,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Urinalysis Dip Stick Tc,3008100001,CDM,300,RC,81000,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Bcr/Abl1 Mutation, Sequencing (Ref Lab)",3008117001,CDM,300,RC,81170,HCPCS,,,facility,both,,,,583,437.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bcr/Abl1 Mutation, Sequencing (Ref Lab)",3008117001,CDM,300,RC,81170,HCPCS,,,facility,both,,,,583,437.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tpmt Genetics Test (Outside Ref Lab),3008118001,CDM,300,RC,81180,HCPCS,,,facility,both,,,,569,426.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bcr/Abl 1 Gene Major Bp (Ref Lab),3008120601,CDM,300,RC,81206,HCPCS,,,facility,both,,,,427,320.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bcr/Abl 1 Gene Major Bp (Ref Lab),3008120601,CDM,300,RC,81206,HCPCS,,,facility,both,,,,159,119.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bcr/Abl1, P210, Quant, Monitor (Ref Lab)",3008120602,CDM,300,RC,81206,HCPCS,,,facility,both,,,,467,350.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bcr/Abl1, P210, Quant, Monitor (Ref Lab)",3008120602,CDM,300,RC,81206,HCPCS,,,facility,both,,,,443,332.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bcr/Abl1 Gene Major Bp (Ref Lab),3008120603,CDM,300,RC,81206,HCPCS,,,facility,both,,,,350,262.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bcr/Abl,P190,Mrna Detect,Rtpcr (Ref Lab)",3008120701,CDM,300,RC,81207,HCPCS,,,facility,both,,,,678,508.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bcr/Abl,P190,Mrna Detect,Rtpcr (Ref Lab)",3008120701,CDM,300,RC,81207,HCPCS,,,facility,both,,,,678,508.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bcr/Abl 1 Gene Minor Bp (Ref Lab),3008120702,CDM,300,RC,81207,HCPCS,,,facility,both,,,,377,282.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bcr/Abl 1 Gene Minor Bp (Ref Lab),3008120702,CDM,300,RC,81207,HCPCS,,,facility,both,,,,140,105,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bcr/Abl1 Gene Minor Bp (Ref Lab),3008120703,CDM,300,RC,81207,HCPCS,,,facility,both,,,,309,231.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bcr/Abl 1 Gene Other Bp (Ref Lab),3008120801,CDM,300,RC,81208,HCPCS,,,facility,both,,,,419,314.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bcr/Abl 1 Gene Other Bp (Ref Lab),3008120801,CDM,300,RC,81208,HCPCS,,,facility,both,,,,207,155.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bcr/Abl1 Gene Other Bp (Ref Lab),3008120802,CDM,300,RC,81208,HCPCS,,,facility,both,,,,273,204.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calr Ex9, Hematologics (Ref Lab)",3008121901,CDM,300,RC,81219,HCPCS,,,facility,both,,,,380,285,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calr Analysis, Myeloprolif-Mpn (Ref Lab)",3008121902,CDM,300,RC,81219,HCPCS,,,facility,both,,,,599,449.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calr,Gene Mutation,Exon 9,Rflx (Ref Lab)",3008121903,CDM,300,RC,81219,HCPCS,,,facility,both,,,,599,449.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cftrz-Cftr Gene, Full Gene Analysis",3008122201,CDM,300,RC,81222,HCPCS,,,facility,both,,,,1205,903.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cftrz-Cftr Gene, Full Gene Analysis",3008122201,CDM,300,RC,81222,HCPCS,,,facility,both,,,,1048,786,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Cftrz-Cftr Gene, Full Gene Analysis",3008122301,CDM,300,RC,81223,HCPCS,,,facility,both,,,,2248,1686,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cftrz-Cftr Gene, Full Gene Analysis",3008122301,CDM,300,RC,81223,HCPCS,,,facility,both,,,,2248,1686,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cytochrome P450 2C19 Genotype (Ref Lab),3008122501,CDM,300,RC,81225,HCPCS,,,facility,both,,,,862,646.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyp2C19 Gene Com Variants (Ref Lab),3008122502,CDM,300,RC,81225,HCPCS,,,facility,both,,,,862,646.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyp2C19 Gene Com Variants (Ref Lab),3008122502,CDM,300,RC,81225,HCPCS,,,facility,both,,,,862,646.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  2C19R-Cytochrome, P450 2C19 Genotype, Varies",3008122503,CDM,300,RC,81225,HCPCS,,,facility,both,,,,991,743.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  2C19R-Cytochrome, P450 2C19 Genotype, Varies",3008122503,CDM,300,RC,81225,HCPCS,,,facility,both,,,,862,646.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cyp2D6 Gene Com Variants (Ref Lab),3008122601,CDM,300,RC,81226,HCPCS,,,facility,both,,,,519,389.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyp2C9 Gene Com Variants (Ref Lab),3008122701,CDM,300,RC,81227,HCPCS,,,facility,both,,,,696,522,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cmacb-Chromosoml Microarry,Bld (Ref Lab)",3008122901,CDM,300,RC,81229,HCPCS,,,facility,both,,,,2070,1552.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cmacb-Chromosoml Microarry,Bld (Ref Lab)",3008122901,CDM,300,RC,81229,HCPCS,,,facility,both,,,,2070,1552.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Yp3A4 Gene Com Variants (Ref Lab),3008123001,CDM,300,RC,81230,HCPCS,,,facility,both,,,,599,449.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyp3A5 Gene Com Variants  (Ref Lab),3008123101,CDM,300,RC,81231,HCPCS,,,facility,both,,,,667,500.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyp3A5 Gene Com Variants  (Ref Lab),3008123101,CDM,300,RC,81231,HCPCS,,,facility,both,,,,667,500.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dpydg-Dpyd Full Gene Sequencing,3008123201,CDM,300,RC,81232,HCPCS,,,facility,both,,,,945,708.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dpydg-Dpyd Full Gene Sequencing,3008123201,CDM,300,RC,81232,HCPCS,,,facility,both,,,,822,616.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Dpydz - Dpyd (Dihydropyrimidine Dehydrogenase) (Eg, 5-Fluorouracil/5-Fu And Capecitabine Dru",3008123202,CDM,300,RC,81232,HCPCS,,,facility,both,,,,822,616.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Dpydz - Dpyd (Dihydropyrimidine Dehydrogenase) (Eg, 5-Fluorouracil/5-Fu And Capecitabine Dru",3008123202,CDM,300,RC,81232,HCPCS,,,facility,both,,,,822,616.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fdm1-Dmpk Dna Test (Dm1),3008123401,CDM,300,RC,81234,HCPCS,,,facility,both,,,,1128,846,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fdm1-Dmpk Dna Test (Dm1),3008123401,CDM,300,RC,81234,HCPCS,,,facility,both,,,,981,735.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Incyte-Egfr Mutation Analysis (Ref Lab),3008123501,CDM,300,RC,81235,HCPCS,,,facility,both,,,,630,472.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Gnhmb-F9 Full Gene Sequence,3008123801,CDM,300,RC,81238,HCPCS,,,facility,both,,,,2021,1515.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Gnhmb-F9 Full Gene Sequence,3008123801,CDM,300,RC,81238,HCPCS,,,facility,both,,,,2021,1515.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc F2 Prothrombin Gene Analysis,3008124001,CDM,300,RC,81240,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Prothrombin G20210A Mutation,B",3008124002,CDM,300,RC,81240,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Prothrombin G20210A Mutation,B",3008124002,CDM,300,RC,81240,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Prothrombin (F2) G20210A Vari,3008124003,CDM,300,RC,81240,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Aathr-F2 (Prothrombin, Coagulation Factor Ii) (Eg, Hereditary Hypercoagulability) Gene A",3008124004,CDM,300,RC,81240,HCPCS,,,facility,both,,,,263,197.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Aathr-F2 (Prothrombin, Coagulation Factor Ii) (Eg, Hereditary Hypercoagulability) Gene A",3008124004,CDM,300,RC,81240,HCPCS,,,facility,both,,,,229,171.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc F5 Leiden Variant Gene Anlys (Ref Lab),3008124101,CDM,300,RC,81241,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Factor V Leiden R506Q Mutation (Ref Lab),3008124102,CDM,300,RC,81241,HCPCS,,,facility,both,,,,302,226.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Factor V Leiden R506Q Mutation (Ref Lab),3008124102,CDM,300,RC,81241,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  F5Dna-Factor V Leiden (R506Q) Mutation, B",3008124103,CDM,300,RC,81241,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  F5Dna-Factor V Leiden (R506Q) Mutation, B",3008124103,CDM,300,RC,81241,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Fragile X Syndrome, Molecular (Ref Lab)",3008124301,CDM,300,RC,81243,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo _G127-Gjb2 Gene Analysis Known Familial Variants,3008125301,CDM,300,RC,81253,HCPCS,,,facility,both,,,,551,413.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo _G127-Gjb2 Gene Analysis Known Familial Variants,3008125301,CDM,300,RC,81253,HCPCS,,,facility,both,,,,551,413.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hfe-Hemochromatosis Hfe, Blood (Ref Lab)",3008125601,CDM,300,RC,81256,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hfe-Hemochromatosis Hfe, Blood (Ref Lab)",3008125601,CDM,300,RC,81256,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Csfp-Hba1/Hba2 Gene Analysis Common Deletions/Variant,3008125701,CDM,300,RC,81257,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Csfp-Hba1/Hba2 Gene Analysis Common Deletions/Variant,3008125701,CDM,300,RC,81257,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bcell Igh Gene Rearrangement (Ref Lab),3008126101,CDM,300,RC,81261,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bcell Igh Gene Rearrangement (Ref Lab),3008126101,CDM,300,RC,81261,HCPCS,,,facility,both,,,,316,237,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Immunoglobulin Gene Rearrange (Ref Lab),3008126102,CDM,300,RC,81261,HCPCS,,,facility,both,,,,588,441,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunoglobulin Gene Rearrange (Ref Lab),3008126102,CDM,300,RC,81261,HCPCS,,,facility,both,,,,316,237,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bcgr Igh Gene Rearrange Amp Meth,3008126103,CDM,300,RC,81261,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Bcgr Igh Gene Rearrange Amp Meth,3008126103,CDM,300,RC,81261,HCPCS,,,facility,both,,,,294,220.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cll Ighv Mutation Analysis (Ref Lab),3008126301,CDM,300,RC,81263,HCPCS,,,facility,both,,,,862,646.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Igh Somatic Hypermutatn,B-Cell (Ref Lab)",3008126302,CDM,300,RC,81263,HCPCS,,,facility,both,,,,767,575.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Igh Somatic Hypermutatn,B-Cell (Ref Lab)",3008126302,CDM,300,RC,81263,HCPCS,,,facility,both,,,,752,564,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bcell Igk Gene Rearrangement (Ref Lab),3008126401,CDM,300,RC,81264,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bcell Igk Gene Rearrangement (Ref Lab),3008126401,CDM,300,RC,81264,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bcgr Igk Rearrangeabn Clonal Pop,3008126402,CDM,300,RC,81264,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Bcgr Igk Rearrangeabn Clonal Pop,3008126402,CDM,300,RC,81264,HCPCS,,,facility,both,,,,294,220.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Alpha-Globin Gene Analysis (Ref Lab),3008126901,CDM,300,RC,81269,HCPCS,,,facility,both,,,,426,319.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Alpha-Globin Gene Analysis (Ref Lab),3008126901,CDM,300,RC,81269,HCPCS,,,facility,both,,,,426,319.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Jak2 Gene Analysis (Ref Lab),3008127001,CDM,300,RC,81270,HCPCS,,,facility,both,,,,242,181.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Jak2 Exon 12-15 Sequence, Rflx (Ref Lab)",3008127002,CDM,300,RC,81270,HCPCS,,,facility,both,,,,240,180,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Jak2 Exon 12-15 Sequence, Rflx (Ref Lab)",3008127002,CDM,300,RC,81270,HCPCS,,,facility,both,,,,240,180,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mpn - Jak2 V617F,Calr,Mpl Rflx (Ref Lab)",3008127003,CDM,300,RC,81270,HCPCS,,,facility,both,,,,242,181.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mpn - Jak2 V617F,Calr,Mpl Rflx (Ref Lab)",3008127003,CDM,300,RC,81270,HCPCS,,,facility,both,,,,242,181.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hematologics- Zb25F Jak2 V617F (Ref Lab),3008127004,CDM,300,RC,81270,HCPCS,,,facility,both,,,,412,309,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Huntington Molecular Analysis (Ref Lab),3008127101,CDM,300,RC,81271,HCPCS,,,facility,both,,,,408,306,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C-Kit Gene Analysis D816V (Ref Lab),3008127301,CDM,300,RC,81273,HCPCS,,,facility,both,,,,776,582,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C-Kit Gene Analysis D816V (Ref Lab),3008127301,CDM,300,RC,81273,HCPCS,,,facility,both,,,,776,582,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mgmt Gene Promoter Methyl Alys (Ref Lab),3008128701,CDM,300,RC,81287,HCPCS,,,facility,both,,,,645,483.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mgmt Gene Promoter Methyl Alys (Ref Lab),3008128701,CDM,300,RC,81287,HCPCS,,,facility,both,,,,645,483.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mthfr C677T Mutation Analysis (Ref Lab),3008129101,CDM,300,RC,81291,HCPCS,,,facility,both,,,,130,97.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Mlh1 Gene Analysis Full Sequence Analysis,3008129201,CDM,300,RC,81292,HCPCS,,,facility,both,,,,249,186.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Mlh1 Gene Analysis Full Sequence Analysis,3008129201,CDM,300,RC,81292,HCPCS,,,facility,both,,,,249,186.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Msh2 Gene Analysis Full Sequence Analysis,3008129501,CDM,300,RC,81295,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Msh2 Gene Analysis Full Sequence Analysis,3008129501,CDM,300,RC,81295,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Msh6 Gene Analysis Full Sequence Analysis,3008129801,CDM,300,RC,81298,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Msh6 Gene Analysis Full Sequence Analysis,3008129801,CDM,300,RC,81298,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Palb2 Gene Analysis Full Gene Sequence,3008130701,CDM,300,RC,81307,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Palb2 Gene Analysis Full Gene Sequence,3008130701,CDM,300,RC,81307,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pml/Rar T(15;17) By Rt-Pcr (Ref Lab),3008131501,CDM,300,RC,81315,HCPCS,,,facility,both,,,,690,517.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pml/Rar T(15;17) By Rt-Pcr (Ref Lab),3008131501,CDM,300,RC,81315,HCPCS,,,facility,both,,,,667,500.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Brgyp-Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non-Pol",3008131901,CDM,300,RC,81319,HCPCS,,,facility,both,,,,831,623.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Brgyp-Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non-Pol",3008131901,CDM,300,RC,81319,HCPCS,,,facility,both,,,,723,542.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Pms2 Gene Analysis Duplication/Deletion Variants,3008131902,CDM,300,RC,81319,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Pms2 Gene Analysis Duplication/Deletion Variants,3008131902,CDM,300,RC,81319,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Pmp22 Gene, Deletion/Duplicatn (Ref Lab)",3008132401,CDM,300,RC,81324,HCPCS,,,facility,both,,,,959,719.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pmp22 Gene, Deletion/Duplicatn (Ref Lab)",3008132401,CDM,300,RC,81324,HCPCS,,,facility,both,,,,670,502.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Prader-Willi/Angelman Syndrome (Ref Lab),3008133101,CDM,300,RC,81331,HCPCS,,,facility,both,,,,419,314.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prader-Willi/Angelman Syndrome (Ref Lab),3008133101,CDM,300,RC,81331,HCPCS,,,facility,both,,,,419,314.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Trb Gene Rearrange Amplify (Ref Lab),3008134001,CDM,300,RC,81340,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hematologics - Zc25G Trb, Beta (Ref Lab)",3008134002,CDM,300,RC,81340,HCPCS,,,facility,both,,,,538,403.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tcr V-Beta Reper Spectratyping (Ref Lab),3008134003,CDM,300,RC,81340,HCPCS,,,facility,both,,,,1431,1073.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tcr V-Beta Reper Spectratyping (Ref Lab),3008134003,CDM,300,RC,81340,HCPCS,,,facility,both,,,,1431,1073.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogen/T-Cel Receptr Beta Gene (Ref Lab),3008134004,CDM,300,RC,81340,HCPCS,,,facility,both,,,,706,529.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Tcgr Trb Gene Rearrange Amplify,3008134005,CDM,300,RC,81340,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Tcgr Trb Gene Rearrange Amplify,3008134005,CDM,300,RC,81340,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Trg Gene Rearrange Anal (Ref Lab),3008134201,CDM,300,RC,81342,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hematologics - Zb27D Trg,Gamma (Ref Lab)",3008134202,CDM,300,RC,81342,HCPCS,,,facility,both,,,,524,393,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Tcgr Trg Gene Rearrangement Anal,3008134203,CDM,300,RC,81342,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Tcgr Trg Gene Rearrangement Anal,3008134203,CDM,300,RC,81342,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Csfp-Hbb Common Variants,3008136101,CDM,300,RC,81361,HCPCS,,,facility,both,,,,182,136.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Csfp-Hbb Common Variants,3008136101,CDM,300,RC,81361,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hla A-B-C Disease Type Low Res (Ref Lab),3008137201,CDM,300,RC,81372,HCPCS,,,facility,both,,,,697,522.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hla A-B-C Disease Type Low Res (Ref Lab),3008137201,CDM,300,RC,81372,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hla I Low Resolution One Antigen Equivalent Each,3008137401,CDM,300,RC,81374,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hla Dq Alpha 1 (Ref Lab),3008137601,CDM,300,RC,81376,HCPCS,,,facility,both,,,,315,236.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hla Dq Alpha 1 (Ref Lab),3008137601,CDM,300,RC,81376,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hla Dq Beta 1 (Ref Lab),3008137602,CDM,300,RC,81376,HCPCS,,,facility,both,,,,315,236.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hla Dq Beta 1 (Ref Lab),3008137602,CDM,300,RC,81376,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hla-Dq Alpha 1 (Ref Lab),3008137603,CDM,300,RC,81376,HCPCS,,,facility,both,,,,261,195.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hla-Dq Beta 1 (Ref Lab),3008137604,CDM,300,RC,81376,HCPCS,,,facility,both,,,,261,195.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cdcom Hla Ii Typing 1 Locus Lr,3008137605,CDM,300,RC,81376,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cdcom Hla Ii Typing 1 Locus Lr,3008137605,CDM,300,RC,81376,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cdcom Hla Ii Typing 1 Locus Lr,3008137606,CDM,300,RC,81376,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cdcom Hla Ii Typing 1 Locus Lr,3008137606,CDM,300,RC,81376,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hla I Typing 1 Allele Hr (Ref Lab),3008138101,CDM,300,RC,81381,HCPCS,,,facility,both,,,,293,219.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hla-A3101 Genotype (Ref Lab),3008138102,CDM,300,RC,81381,HCPCS,,,facility,both,,,,396,297,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hla-B1502 Genotype (Ref Lab),3008138103,CDM,300,RC,81381,HCPCS,,,facility,both,,,,396,297,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Hl57R-Hla-B*57:01 Genotype, Pharmacogenomics, Varies",3008138104,CDM,300,RC,81381,HCPCS,,,facility,both,,,,370,277.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Hl57R-Hla-B*57:01 Genotype, Pharmacogenomics, Varies",3008138104,CDM,300,RC,81381,HCPCS,,,facility,both,,,,224,168,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kcnq1Ot1 Methylation Analysis (Ref Lab),3008140101,CDM,300,RC,81401,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc H19 Methylation Analysis (Ref Lab),3008140102,CDM,300,RC,81401,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mpl Mut, Hematologics (Ref Lab)",3008140201,CDM,300,RC,81402,HCPCS,,,facility,both,,,,380,285,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mpl Exon 10 Mutation Detect, B (Ref Lab)",3008140301,CDM,300,RC,81403,HCPCS,,,facility,both,,,,515,386.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hematologic-Zb3Rs Jak2 Exon 12 (Ref Lab),3008140302,CDM,300,RC,81403,HCPCS,,,facility,both,,,,396,297,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fam Hemophago Lymph Fhl2 Phrf1 (Ref Lab),3008140303,CDM,300,RC,81403,HCPCS,,,facility,both,,,,614,460.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Molecular Extended Rc Genotype/Phenotype,3008140304,CDM,300,RC,81403,HCPCS,,,facility,both,,,,592,444,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Brgyp-Molecular Pathology Procedure, Level 4",3008140305,CDM,300,RC,81403,HCPCS,,,facility,both,,,,757,567.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Brgyp-Molecular Pathology Procedure, Level 4",3008140305,CDM,300,RC,81403,HCPCS,,,facility,both,,,,658,493.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Non Mayo-Molecular Extended Red Cell Phenotype,3008140306,CDM,300,RC,81403,HCPCS,,,facility,both,,,,597,447.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Non Mayo-Molecular Extended Red Cell Phenotype,3008140306,CDM,300,RC,81403,HCPCS,,,facility,both,,,,519,389.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Vhl Gene,Erythrocytosis Mutatn (Ref Lab)",3008140401,CDM,300,RC,81404,HCPCS,,,facility,both,,,,774,580.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vhl Gene,Erythrocytosis Mutatn (Ref Lab)",3008140401,CDM,300,RC,81404,HCPCS,,,facility,both,,,,774,580.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Edsgp Ehlers-Danlos Syndrome Gene Panel,3008140801,CDM,300,RC,81408,HCPCS,,,facility,both,,,,1765,1323.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Edsgp Ehlers-Danlos Syndrome Gene Panel,3008140801,CDM,300,RC,81408,HCPCS,,,facility,both,,,,1535,1151.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Edsgp Ehlers-Danlos Syndrome Gene Panel,3008140802,CDM,300,RC,81408,HCPCS,,,facility,both,,,,1765,1323.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Edsgp Ehlers-Danlos Syndrome Gene Panel,3008140802,CDM,300,RC,81408,HCPCS,,,facility,both,,,,1535,1151.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Mfbng-Fbn1 Full Gene Analysis,3008140803,CDM,300,RC,81408,HCPCS,,,facility,both,,,,3420,2565,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Mfbng-Fbn1 Full Gene Analysis,3008140803,CDM,300,RC,81408,HCPCS,,,facility,both,,,,2974,2230.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Nf1Z-Nf1 Full Gene Analysis,3008140804,CDM,300,RC,81408,HCPCS,,,facility,both,,,,2479,1859.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Nf1Z-Nf1 Full Gene Analysis,3008140804,CDM,300,RC,81408,HCPCS,,,facility,both,,,,2156,1617,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Mfrgg-Test For Detecting Genes Associated With Heart Disease, Genomic Sequence Analysis P",3008141001,CDM,300,RC,81410,HCPCS,,,facility,both,,,,3746,2809.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Mfrgg-Test For Detecting Genes Associated With Heart Disease, Genomic Sequence Analysis P",3008141001,CDM,300,RC,81410,HCPCS,,,facility,both,,,,3257,2442.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Hhlp Hearing Loss Genomic Sequence Analysis 60 Genes,3008143001,CDM,300,RC,81430,HCPCS,,,facility,both,,,,3077,2307.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Hhlp Hearing Loss Genomic Sequence Analysis 60 Genes,3008143001,CDM,300,RC,81430,HCPCS,,,facility,both,,,,2676,2007,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Ahlp- Test For Detecting Genes Causing Hearing Loss Genomic Sequence Analysis Panel, At Leas",3008143002,CDM,300,RC,81430,HCPCS,,,facility,both,,,,3122,2341.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Ahlp- Test For Detecting Genes Causing Hearing Loss Genomic Sequence Analysis Panel, At Leas",3008143002,CDM,300,RC,81430,HCPCS,,,facility,both,,,,3122,2341.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Hhlp Hearing Loss Dup/Del Analysis,3008143101,CDM,300,RC,81431,HCPCS,,,facility,both,,,,1288,966,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Hhlp Hearing Loss Dup/Del Analysis,3008143101,CDM,300,RC,81431,HCPCS,,,facility,both,,,,1120,840,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ahlp-Audiologene Hearing Loss Panel,3008143102,CDM,300,RC,81431,HCPCS,,,facility,both,,,,1306,979.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ahlp-Audiologene Hearing Loss Panel,3008143102,CDM,300,RC,81431,HCPCS,,,facility,both,,,,1306,979.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hpglp-Heredtry Nurondcrn Tum Dsrdrs Gen Seq Anal 6 Gen,3008143701,CDM,300,RC,81437,HCPCS,,,facility,both,,,,3537,2652.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Hpglp-Heredtry Nurondcrn Tum Dsrdrs Gen Seq Anal 6 Gen,3008143701,CDM,300,RC,81437,HCPCS,,,facility,both,,,,3537,2652.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Nsrgg-Noonan Spectrum Disorders Gen Seq Analys 12 Gen,3008144201,CDM,300,RC,81442,HCPCS,,,facility,both,,,,2689,2016.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Nsrgg-Noonan Spectrum Disorders Gen Seq Analys 12 Gen,3008144201,CDM,300,RC,81442,HCPCS,,,facility,both,,,,2689,2016.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Nghha-Genetic Testing For Severe Inherited Conditions,3008144301,CDM,300,RC,81443,HCPCS,,,facility,both,,,,7657,5742.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Nghha-Genetic Testing For Severe Inherited Conditions,3008144301,CDM,300,RC,81443,HCPCS,,,facility,both,,,,6658,4993.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Autog - Genetic Testing For Severe Inherited Conditions,3008144302,CDM,300,RC,81443,HCPCS,,,facility,both,,,,4118,3088.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Autog - Genetic Testing For Severe Inherited Conditions,3008144302,CDM,300,RC,81443,HCPCS,,,facility,both,,,,4118,3088.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Immau-Genetic Testing For Severe Inherited Conditions,3008144303,CDM,300,RC,81443,HCPCS,,,facility,both,,,,2989,2241.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Rabmp-Genetic Testing For Severe Inherited Conditions,3008144304,CDM,300,RC,81443,HCPCS,,,facility,both,,,,3321,2490.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Rabmp-Genetic Testing For Severe Inherited Conditions,3008144304,CDM,300,RC,81443,HCPCS,,,facility,both,,,,3321,2490.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ataxp-Genetic Testing For Severe Inherited Conditions,3008144305,CDM,300,RC,81443,HCPCS,,,facility,both,,,,3852,2889,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ataxp-Genetic Testing For Severe Inherited Conditions,3008144305,CDM,300,RC,81443,HCPCS,,,facility,both,,,,3852,2889,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomic-Nt Melanoma Profile (Ref Lab),3008144501,CDM,300,RC,81445,HCPCS,,,facility,both,,,,1265,948.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hereditary Motor &Sensory, Ngs (Ref Lab)",3008144801,CDM,300,RC,81448,HCPCS,,,facility,both,,,,2846,2134.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Sarcp-Targeted Genomic Sequence Analysis Panel Of Rna Of 51 Or Greater Genes Associated With,3008145601,CDM,300,RC,81456,HCPCS,,,facility,both,,,,3971,2978.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Mitop-Mitochondrial Full Genome Analysis,3008146501,CDM,300,RC,81465,HCPCS,,,facility,both,,,,1379,1034.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Mitop-Mitochondrial Full Genome Analysis,3008146501,CDM,300,RC,81465,HCPCS,,,facility,both,,,,1199,899.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Atg16L1 Snp (Outside Ref Lab),3008147917,CDM,300,RC,81479,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ecm1 Snp (Outside Ref Lab),3008147918,CDM,300,RC,81479,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nkx2-3 Snp (Outside Ref Lab),3008147919,CDM,300,RC,81479,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Stat3 Snp (Outside Ref Lab),3008147920,CDM,300,RC,81479,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Quad Screen (Second Trimester) Maternal, Serum (Ref Lab)",3008151101,CDM,300,RC,81511,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Quad Screen (Second Trimester) Maternal, Serum (Ref Lab)",3008151101,CDM,300,RC,81511,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg,3008151401,CDM,300,RC,81514,HCPCS,,,facility,both,,,,509,381.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg,3008151401,CDM,300,RC,81514,HCPCS,,,facility,both,,,,443,332.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Mgmr Ria Nonantibody,3008151901,CDM,300,RC,81519,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Mgmr Ria Nonantibody,3008151901,CDM,300,RC,81519,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Mgmr Ria Nonantibody,3008151902,CDM,300,RC,81519,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Fibrotest-Actitest,Serum  (Ref Lab)",3008159601,CDM,300,RC,81596,HCPCS,,,facility,both,,,,346,259.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Microalbumin Semiquant Tc (Poc),3008204401,CDM,300,RC,82044,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Mayo Amh1-Assay Of Anti-Mullerian Hormone,3008216601,CDM,300,RC,82166,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Amh1-Assay Of Anti-Mullerian Hormone,3008216601,CDM,300,RC,82166,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Gastrocult,3008227101,CDM,300,RC,82271,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Mayo Mev1-Hemoglobin Sulfhemoglobin Quantitative,3008306001,CDM,300,RC,83060,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Mev1-Hemoglobin Sulfhemoglobin Quantitative,3008306001,CDM,300,RC,83060,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fgnrh-Luteinizing Releasing Factor (Lrh),3008372701,CDM,300,RC,83727,HCPCS,,,facility,both,,,,309,231.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Thiocyanate, Serum",3008443001,CDM,300,RC,84430,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Thiocyanate, Serum",3008443001,CDM,300,RC,84430,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Tpmt3-Evaluation Of Thiopurine S-Methyltransferase (Tpmt),3008443301,CDM,300,RC,84433,HCPCS,,,facility,both,,,,354,265.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Arbi-Acetylcholine Receptor Binding Antibody,3008604101,CDM,300,RC,86041,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Arbi-Acetylcholine Receptor Binding Antibody,3008604101,CDM,300,RC,86041,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mgmr-Acetylcholine Receptor Binding Antibody,3008604102,CDM,300,RC,86041,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Mgmr-Acetylcholine Receptor Binding Antibody,3008604102,CDM,300,RC,86041,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Acmfs-Acetylcholine Receptor Modulating Antibody,3008604301,CDM,300,RC,86043,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Acmfs-Acetylcholine Receptor Modulating Antibody,3008604301,CDM,300,RC,86043,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Musk-Muscle-Specific Kinase Antibody,3008636601,CDM,300,RC,86366,HCPCS,,,facility,both,,,,776,582,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Musk-Muscle-Specific Kinase Antibody,3008636601,CDM,300,RC,86366,HCPCS,,,facility,both,,,,776,582,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Datr-Red Blood Cell Antibody Detection Test, Direct",3008688001,CDM,300,RC,86880,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Spagr-Blood Typing For Red Blood Cell Antigens,3008690501,CDM,300,RC,86905,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Sttx32-Red Cell Antigen Typing,3008690502,CDM,300,RC,86905,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fresh Frozen Plasma, Thawing, Each Unit",3008692701,CDM,300,RC,86927,HCPCS,,,facility,both,,,,182,136.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fresh Frozen Plasma, Thawing, Each Unit",3008692701,CDM,300,RC,86927,HCPCS,,,facility,both,,,,182,136.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Ismy-Cultyp Nucleic Acid Sequencing Meth Ea Isolate,3008715301,CDM,300,RC,87153,HCPCS,,,facility,both,,,,134,100.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Ismy-Cultyp Nucleic Acid Sequencing Meth Ea Isolate,3008715301,CDM,300,RC,87153,HCPCS,,,facility,both,,,,134,100.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Hbagq-Hep B Surface Antigen, Quantitative",3008746701,CDM,300,RC,87467,HCPCS,,,facility,both,,,,276,207,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Hbagq-Hep B Surface Antigen, Quantitative",3008746701,CDM,300,RC,87467,HCPCS,,,facility,both,,,,276,207,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Szdia Fcims-Flow Cytometry Technique For Dna Or Cell Analysis, 9 To 15 Markers",3008818801,CDM,300,RC,88188,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Szdia Fcims-Flow Cytometry Technique For Dna Or Cell Analysis, 9 To 15 Markers",3008818801,CDM,300,RC,88188,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Flow Interpretation 9-15 Markers,3008818802,CDM,300,RC,88188,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Flow Interpretation 9-15 Markers,3008818802,CDM,300,RC,88188,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cllmd-Flow Cytometry Interpj 9-15 Markers,3008818803,CDM,300,RC,88188,HCPCS,,,facility,both,,,,214,160.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Metaphases, 15-20 (Ref Lab)",3008826201,CDM,300,RC,88262,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Metaphases, >=10 (Ref Lab)",3008827301,CDM,300,RC,88273,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Surg Em Complete Tc (Outside Ref Lab),3008834801,CDM,300,RC,88348,HCPCS,,,facility,both,,,,1570,1177.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igm Immunofluorescence (Ref Lab),3008835001,CDM,300,RC,88350,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc  Immunofluor Antb Addl Stain (Ref Lab),3008835002,CDM,300,RC,88350,HCPCS,,,facility,both,,,,252,189,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ibd Specific Panca Ifa Dnase (Outside Ref Lab),3008835004,CDM,300,RC,88350,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Surg If Addl Tc (Outside Ref Lab),3008835005,CDM,300,RC,88350,HCPCS,,,facility,both,,,,290,217.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cell Count & Diff, Body Fluid",3008905101,CDM,300,RC,89051,HCPCS,,,facility,both,,,,182,136.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cell Count & Diff, Body Fluid",3008905101,CDM,300,RC,89051,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cell Count & Diff, Body Fluid",3008905101,CDM,300,RC,89051,HCPCS,,,facility,both,,,,8.31,6.23,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cell Count & Diff, Body Fluid",3008905101,CDM,300,RC,89051,HCPCS,,,facility,both,,,,27.81,20.86,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Crystal Exam, Joint Fluid",3008906001,CDM,300,RC,89060,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Crystal Exam, Joint Fluid",3008906001,CDM,300,RC,89060,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Crystal Exam, Joint Fluid",3008906001,CDM,300,RC,89060,HCPCS,,,facility,both,,,,8.06,6.04,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Crystal Ident, Synovial Fluid (Ref Lab)",3008906002,CDM,300,RC,89060,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Synovial Fluid, Crystals",3008906003,CDM,300,RC,89060,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Synovial Fluid, Crystals",3008906003,CDM,300,RC,89060,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Eosinophils, Nasal Smear",3008919001,CDM,300,RC,89190,HCPCS,,,facility,both,,,,115,86.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Eosinophils, Nasal Smear",3008919001,CDM,300,RC,89190,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Eosinophils, Nasal Smear",3008919001,CDM,300,RC,89190,HCPCS,,,facility,both,,,,6.37,4.78,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Chain Of Custody Process,3009900101,CDM,300,RC,99001,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fern Test,300Q011401,CDM,300,RC,Q0114,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fern Test,300Q011401,CDM,300,RC,Q0114,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fern Test,300Q011401,CDM,300,RC,Q0114,HCPCS,,,facility,both,,,,10.71,8.03,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Mayo Nsfib- Nash-Fibrotest,3010003M01,CDM,301,RC,0003M,HCPCS,,,facility,both,,,,590,442.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc M-Protein Isotype Maldi-Tof Ms (Ref Lab),3010077U01,CDM,301,RC,0077U,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc M-Protein Isotype Maldi-Tof Ms (Ref Lab),3010077U01,CDM,301,RC,0077U,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc M-Protein Isotype Maldi-Tof Ms (Ref Lab),3010077U02,CDM,301,RC,0077U,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
POTASSIUM CHLORIDE IN STERILE  WATER 10 MEQ/100ML SOLN,30113,CDM,636,RC,J3480,HCPCS,990707426,NDC,facility,both,200,ML,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE IN STERILE  WATER 10 MEQ/100ML SOLN,30113,CDM,636,RC,J3480,HCPCS,990707426,NDC,facility,both,400,ML,,4.11,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE IN STERILE  WATER 10 MEQ/100ML SOLN,30113,CDM,636,RC,J3480,HCPCS,338070948,NDC,facility,both,100,ML,,10.57,7.93,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE IN STERILE  WATER 10 MEQ/100ML SOLN,30113,CDM,636,RC,J3480,HCPCS,990707426,NDC,facility,both,100,ML,,11.28,8.46,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-0.9 MEQ/L-% SOLN,30128,CDM,636,RC,J3480,HCPCS,264786500,NDC,facility,both,100,ML,,2.16,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-0.9 MEQ/L-% SOLN,30128,CDM,636,RC,J3480,HCPCS,338069104,NDC,facility,both,100,ML,,1.74,1.31,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-0.9 MEQ/L-% SOLN,30128,CDM,636,RC,J3480,HCPCS,990711509,NDC,facility,both,100,ML,,2.56,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-0.9 MEQ/L-% SOLN,30128,CDM,636,RC,J3480,HCPCS,63323068610,NDC,facility,both,100,ML,,1.95,1.46,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-0.9 MEQ/L-% SOLN 1,000 ML FLEX CONT",30128,CDM,636,RC,J3480,HCPCS,264786500,NDC,facility,both,100,ML,,2.16,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-0.9 MEQ/L-% SOLN 1,000 ML FLEX CONT",30128,CDM,636,RC,J3480,HCPCS,990711509,NDC,facility,both,100,ML,,2.56,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9% NACL WITH KCL 20 MEQ/L SOLUTION 20-0.9 MEQ/L-% SOLN 1,000 ML FLEX CONT",30128,CDM,636,RC,J3480,HCPCS,338069104,NDC,facility,both,100,ML,,1.74,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL WITH KCL 40 MEQ/L SOLUTION 40-0.9 MEQ/L-% SOLN,30129,CDM,636,RC,J3480,HCPCS,338069504,NDC,facility,both,1000,ML,,0.98,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL WITH KCL 40 MEQ/L SOLUTION 40-0.9 MEQ/L-% SOLN,30129,CDM,636,RC,J3480,HCPCS,338069504,NDC,facility,both,1020,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL WITH KCL 40 MEQ/L SOLUTION 40-0.9 MEQ/L-% SOLN,30129,CDM,636,RC,J3480,HCPCS,990711609,NDC,facility,both,1000,ML,,1.48,1.11,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ (1080 MG) TBCR,30132,CDM,250,RC,68084085032,NDC,,,facility,both,1,UN,,12.8,9.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ (1080 MG) TBCR,30132,CDM,250,RC,68382053701,NDC,,,facility,both,1,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ (1080 MG) TBCR,30132,CDM,250,RC,68084085032,NDC,,,facility,both,3,UN,,7.17,5.37,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ (1080 MG) TBCR,30132,CDM,250,RC,68084085032,NDC,,,facility,both,1.5,UN,,7.58,5.68,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ (1080 MG) TBCR,30132,CDM,250,RC,68382053701,NDC,,,facility,both,2,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ (1080 MG) TBCR,30132,CDM,250,RC,68084085032,NDC,,,facility,both,2,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
"Hc Basic Metabolic Panel, Ion Cal",3018004701,CDM,301,RC,80047,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Basic Metabolic Panel, Ion Cal",3018004701,CDM,301,RC,80047,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Basic Metabolic Panel,Totl Cal",3018004801,CDM,301,RC,80048,HCPCS,,,facility,both,,,,169,126.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Basic Metabolic Panel,Totl Cal",3018004801,CDM,301,RC,80048,HCPCS,,,facility,both,,,,72.45,54.34,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Basic Metabolic Panel,Totl Cal",3018004801,CDM,301,RC,80048,HCPCS,,,facility,both,,,,9.31,6.98,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Basic Metabolic Panel,Totl Cal",3018004801,CDM,301,RC,80048,HCPCS,,,facility,both,,,,2.29,1.72,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Neonate Chem Bmp,3018004802,CDM,301,RC,80048,HCPCS,,,facility,both,,,,169,126.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Chem Bmp,3018004802,CDM,301,RC,80048,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Electrolyte Panel,3018005101,CDM,301,RC,80051,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Electrolyte Panel,3018005101,CDM,301,RC,80051,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Electrolyte Panel,3018005101,CDM,301,RC,80051,HCPCS,,,facility,both,,,,7.7,5.78,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Electrolyte Panel,3018005101,CDM,301,RC,80051,HCPCS,,,facility,both,,,,2.59,1.94,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Electrolytes, Poc",3018005102,CDM,301,RC,80051,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Comprehensive Metabolic Panel,3018005301,CDM,301,RC,80053,HCPCS,,,facility,both,,,,172.5,129.38,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Comprehensive Metabolic Panel,3018005301,CDM,301,RC,80053,HCPCS,,,facility,both,,,,86.25,64.69,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Comprehensive Metabolic Panel,3018005301,CDM,301,RC,80053,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Comprehensive Metabolic Panel,3018005301,CDM,301,RC,80053,HCPCS,,,facility,both,,,,11.62,8.72,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Comprehensive Metabolic Panel,3018005301,CDM,301,RC,80053,HCPCS,,,facility,both,,,,2.91,2.18,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Obstetric Panel (No Hiv),3018005501,CDM,301,RC,80055,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lipid Panel,3018006101,CDM,301,RC,80061,HCPCS,,,facility,both,,,,132.25,99.19,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Lipid Panel,3018006101,CDM,301,RC,80061,HCPCS,,,facility,both,,,,115,86.25,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Lipid Panel,3018006101,CDM,301,RC,80061,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Lipid Panel,3018006101,CDM,301,RC,80061,HCPCS,,,facility,both,,,,17.13,12.85,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Lipid Panel,3018006101,CDM,301,RC,80061,HCPCS,,,facility,both,,,,2.11,1.58,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Mayo Zw242-Lipid Panel,3018006102,CDM,301,RC,80061,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw242-Lipid Panel,3018006102,CDM,301,RC,80061,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Renal Function Panel,3018006901,CDM,301,RC,80069,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Renal Function Panel,3018006901,CDM,301,RC,80069,HCPCS,,,facility,both,,,,82.8,62.1,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Renal Function Panel,3018006901,CDM,301,RC,80069,HCPCS,,,facility,both,,,,9.55,7.16,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Renal Function Panel,3018006901,CDM,301,RC,80069,HCPCS,,,facility,both,,,,2.54,1.9,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Acute Hepatitis Panel,3018007401,CDM,301,RC,80074,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatic Function Panel,3018007601,CDM,301,RC,80076,HCPCS,,,facility,both,,,,192,144,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatic Function Panel,3018007601,CDM,301,RC,80076,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatic Function Panel,3018007601,CDM,301,RC,80076,HCPCS,,,facility,both,,,,8.99,6.74,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Hepatic Function Panel,3018007601,CDM,301,RC,80076,HCPCS,,,facility,both,,,,2.51,1.88,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Obstetric Panel With Hiv,3018008101,CDM,301,RC,80081,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Adalimumab Qn W/Rflx To Ab, S",3018014501,CDM,301,RC,80145,HCPCS,,,facility,both,,,,414,310.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Adalimumab Qn W/Rflx To Ab, S",3018014501,CDM,301,RC,80145,HCPCS,,,facility,both,,,,360,270,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Amikacin Level (Ref Lab),3018015001,CDM,301,RC,80150,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amikacin Level (Ref Lab),3018015001,CDM,301,RC,80150,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Amikacin, Peak, Serum (Ref Lab)",3018015002,CDM,301,RC,80150,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Amikacin, Peak, Serum (Ref Lab)",3018015002,CDM,301,RC,80150,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Carbamazepine Level,3018015601,CDM,301,RC,80156,HCPCS,,,facility,both,,,,220,165,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Carbamazepine Level,3018015601,CDM,301,RC,80156,HCPCS,,,facility,both,,,,133,99.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Carbamazepine Level,3018015601,CDM,301,RC,80156,HCPCS,,,facility,both,,,,31.14,23.36,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Carbamazepine Level,3018015601,CDM,301,RC,80156,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Carbamazepine Level,3018015601,CDM,301,RC,80156,HCPCS,,,facility,both,,,,3.32,2.49,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Carbamazepine, Total, S (Ref Lab)",3018015602,CDM,301,RC,80156,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cyclosporin Level, Hplc (Ref Lab)",3018015801,CDM,301,RC,80158,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cyclosporin Level, Hplc (Ref Lab)",3018015801,CDM,301,RC,80158,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Clozapine/Clozaril Level (Ref Lab),3018015901,CDM,301,RC,80159,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Clozapine/Clozaril Level (Ref Lab),3018015901,CDM,301,RC,80159,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Norclozapine Level (Ref Lab),3018015902,CDM,301,RC,80159,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Digoxin Level,3018016201,CDM,301,RC,80162,HCPCS,,,facility,both,,,,176,132,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Digoxin Level,3018016201,CDM,301,RC,80162,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Digoxin Level,3018016201,CDM,301,RC,80162,HCPCS,,,facility,both,,,,14.61,10.96,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Digoxin Level,3018016201,CDM,301,RC,80162,HCPCS,,,facility,both,,,,3.99,2.99,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc  - Drug Screen Quantitative Digoxin Total,3018016202,CDM,301,RC,80162,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc  - Drug Screen Quantitative Digoxin Total,3018016202,CDM,301,RC,80162,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Valproic Acid Level,3018016401,CDM,301,RC,80164,HCPCS,,,facility,both,,,,176,132,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Valproic Acid Level,3018016401,CDM,301,RC,80164,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Valproic Acid Level,3018016401,CDM,301,RC,80164,HCPCS,,,facility,both,,,,15.68,11.76,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Valproic Acid Level,3018016401,CDM,301,RC,80164,HCPCS,,,facility,both,,,,14.89,11.17,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Valproic Acid Level,3018016401,CDM,301,RC,80164,HCPCS,,,facility,both,,,,3,2.25,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Valproic Acid, Total, Serum (Ref Lab)",3018016402,CDM,301,RC,80164,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Valpg Assay Dipropylacetic Acd Tot,3018016403,CDM,301,RC,80164,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Valpg Assay Dipropylacetic Acd Tot,3018016403,CDM,301,RC,80164,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Valproic Acid, Free (Ref Lab)",3018016501,CDM,301,RC,80165,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Valproic Acid, Free (Ref Lab)",3018016501,CDM,301,RC,80165,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Valproic Acid, Free, Serum (Ref Lab)",3018016502,CDM,301,RC,80165,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Valpg Dipropylacetic Acid Free,3018016503,CDM,301,RC,80165,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Valpg Dipropylacetic Acid Free,3018016503,CDM,301,RC,80165,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Felbamate Level (Ref Lab),3018016701,CDM,301,RC,80167,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Felbamate Level (Ref Lab),3018016701,CDM,301,RC,80167,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Evrol - Everolimus, B (Ref Lab)",3018016901,CDM,301,RC,80169,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Evrol - Everolimus, B (Ref Lab)",3018016901,CDM,301,RC,80169,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Gentamicin Level,3018017001,CDM,301,RC,80170,HCPCS,,,facility,both,,,,283,212.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gentamicin Level,3018017001,CDM,301,RC,80170,HCPCS,,,facility,both,,,,151,113.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Gentamicin Level,3018017001,CDM,301,RC,80170,HCPCS,,,facility,both,,,,24.72,18.54,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Gabapentin Level (Neurontin) (Ref Lab),3018017101,CDM,301,RC,80171,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gabapentin Level (Neurontin) (Ref Lab),3018017101,CDM,301,RC,80171,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lamotrigine Level (Ref Lab),3018017501,CDM,301,RC,80175,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lamotrigine Level (Ref Lab),3018017501,CDM,301,RC,80175,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lidocaine Level (Ref Lab),3018017601,CDM,301,RC,80176,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lidocaine Level (Ref Lab),3018017601,CDM,301,RC,80176,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Levetiracetam/Keppra Level (Ref Lab),3018017701,CDM,301,RC,80177,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Levetiracetam/Keppra Level (Ref Lab),3018017701,CDM,301,RC,80177,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lithium Level,3018017801,CDM,301,RC,80178,HCPCS,,,facility,both,,,,148,111,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lithium Level,3018017801,CDM,301,RC,80178,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lithium Level,3018017801,CDM,301,RC,80178,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Lithium Level,3018017801,CDM,301,RC,80178,HCPCS,,,facility,both,,,,9.98,7.48,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Lithium Level,3018017801,CDM,301,RC,80178,HCPCS,,,facility,both,,,,4.56,3.42,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Drug Assay Salicylate,3018017901,CDM,301,RC,80179,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drug Assay Salicylate,3018017901,CDM,301,RC,80179,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mpa - Mycophenolic Acid,Serum (Ref Lab)",3018018001,CDM,301,RC,80180,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mpa - Mycophenolic Acid,Serum (Ref Lab)",3018018001,CDM,301,RC,80180,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Flec Flecanide, Serum",3018018101,CDM,301,RC,80181,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Flec Flecanide, Serum",3018018101,CDM,301,RC,80181,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Trileptal Level (Ref Lab),3018018301,CDM,301,RC,80183,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Trileptal Level (Ref Lab),3018018301,CDM,301,RC,80183,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Phenobarbital Level,3018018401,CDM,301,RC,80184,HCPCS,,,facility,both,,,,206,154.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phenobarbital Level,3018018401,CDM,301,RC,80184,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Phenobarbital Level,3018018401,CDM,301,RC,80184,HCPCS,,,facility,both,,,,38.39,28.79,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Phenobarbital Level,3018018401,CDM,301,RC,80184,HCPCS,,,facility,both,,,,16.83,12.62,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Phenobarbital (Ref Lab),3018018402,CDM,301,RC,80184,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phenobarbital (Ref Lab),3018018402,CDM,301,RC,80184,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phenytoin, Total",3018018501,CDM,301,RC,80185,HCPCS,,,facility,both,,,,208,156,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phenytoin, Total",3018018501,CDM,301,RC,80185,HCPCS,,,facility,both,,,,140,105,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phenytoin, Total",3018018501,CDM,301,RC,80185,HCPCS,,,facility,both,,,,24.5,18.38,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Phenytoin, Total",3018018501,CDM,301,RC,80185,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Phenytoin, Total",3018018501,CDM,301,RC,80185,HCPCS,,,facility,both,,,,3.99,2.99,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Phenytoin, Free, Serum (Ref Lab)",3018018601,CDM,301,RC,80186,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phenytoin, Free, Serum (Ref Lab)",3018018601,CDM,301,RC,80186,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Primidone (Ref Lab),3018018801,CDM,301,RC,80188,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Primidone (Ref Lab),3018018801,CDM,301,RC,80188,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Itcon-Itraconazole, Serum",3018018901,CDM,301,RC,80189,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Pa-Procainamide Level, With Metabolites",3018019201,CDM,301,RC,80192,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sirolimus/Rapamycin Level (Ref Lab),3018019501,CDM,301,RC,80195,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sirolimus/Rapamycin Level (Ref Lab),3018019501,CDM,301,RC,80195,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fk 506 (Tacrolimus) (Ref Lab),3018019701,CDM,301,RC,80197,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fk 506 (Tacrolimus) (Ref Lab),3018019701,CDM,301,RC,80197,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drug Screen Quantitative Tacrolimus,3018019702,CDM,301,RC,80197,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drug Screen Quantitative Tacrolimus,3018019702,CDM,301,RC,80197,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Theophylline, Serum (Ref Lab)",3018019801,CDM,301,RC,80198,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Theophylline, Serum (Ref Lab)",3018019801,CDM,301,RC,80198,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Tobramycin, S (Ref Lab)",3018020001,CDM,301,RC,80200,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tobramycin, S (Ref Lab)",3018020001,CDM,301,RC,80200,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Topiramate Level (Ref Lab),3018020101,CDM,301,RC,80201,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Topiramate Level (Ref Lab),3018020101,CDM,301,RC,80201,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vancomycin Level,3018020201,CDM,301,RC,80202,HCPCS,,,facility,both,,,,212,159,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vancomycin Level,3018020201,CDM,301,RC,80202,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vancomycin Level,3018020201,CDM,301,RC,80202,HCPCS,,,facility,both,,,,14.89,11.17,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Vancomycin Level,3018020201,CDM,301,RC,80202,HCPCS,,,facility,both,,,,7.19,5.39,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Zonisamide Level (Ref Lab),3018020301,CDM,301,RC,80203,HCPCS,,,facility,both,,,,170,127.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Zonisamide Level (Ref Lab),3018020301,CDM,301,RC,80203,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Rufi-Measurement Of Rufinamide,3018021001,CDM,301,RC,80210,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Rufi-Measurement Of Rufinamide,3018021001,CDM,301,RC,80210,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Infliximab Level (Ref Lab),3018023001,CDM,301,RC,80230,HCPCS,,,facility,both,,,,351,263.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Infliximab Level (Ref Lab),3018023001,CDM,301,RC,80230,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Laco - Lacosamide (Ref Lab),3018023501,CDM,301,RC,80235,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Laco - Lacosamide (Ref Lab),3018023501,CDM,301,RC,80235,HCPCS,,,facility,both,,,,148,111,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Vedolizumab Qn, S (Ref Lab)",3018028001,CDM,301,RC,80280,HCPCS,,,facility,both,,,,270,202.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Voriconazole, Serum (Ref Lab)",3018028501,CDM,301,RC,80285,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Voriconazole, Serum (Ref Lab)",3018028501,CDM,301,RC,80285,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Amiodarone Level (Ref Lab),3018029901,CDM,301,RC,80299,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amiodarone Level (Ref Lab),3018029901,CDM,301,RC,80299,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Methotrexate Level (Ref Lab),3018029902,CDM,301,RC,80299,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Methotrexate Level (Ref Lab),3018029902,CDM,301,RC,80299,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Voriconazole Level, Hplc (Ref Lab)",3018029903,CDM,301,RC,80299,HCPCS,,,facility,both,,,,374,280.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Quantitative Assay Drug (Ref Lab),3018029904,CDM,301,RC,80299,HCPCS,,,facility,both,,,,174,130.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flecainide, Serum (Ref Lab)",3018029905,CDM,301,RC,80299,HCPCS,,,facility,both,,,,123,92.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flecainide, Serum (Ref Lab)",3018029905,CDM,301,RC,80299,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Eslicarbazepine (Ref Lab),3018029906,CDM,301,RC,80299,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rivaroxaban, Anti-Xa, Plasma (Ref Lab)",3018029907,CDM,301,RC,80299,HCPCS,,,facility,both,,,,281,210.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rivaroxaban, Anti-Xa, Plasma (Ref Lab)",3018029907,CDM,301,RC,80299,HCPCS,,,facility,both,,,,281,210.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Apixaban, Anti-Xa, Plasma (Ref Lab)",3018029908,CDM,301,RC,80299,HCPCS,,,facility,both,,,,281,210.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Methotrexate Level,3018029909,CDM,301,RC,80299,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Methotrexate Level,3018029909,CDM,301,RC,80299,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Methotrexate Level,3018029909,CDM,301,RC,80299,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Methotrexate Level,3018029909,CDM,301,RC,80299,HCPCS,,,facility,both,,,,20.5,15.38,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Kh Mayo  Dexa/Fdxm-Dexamethasone,3018029911,CDM,301,RC,80299,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Dexa/Fdxm-Dexamethasone,3018029911,CDM,301,RC,80299,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Thio-Thiopurine Metabolites, Whole Blood",3018029912,CDM,301,RC,80299,HCPCS,,,facility,both,,,,276,207,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Thio-Thiopurine Metabolites, Whole Blood",3018029912,CDM,301,RC,80299,HCPCS,,,facility,both,,,,246,184.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ustek-Ustekinumab Quant With Antibodies, Serum",3018029913,CDM,301,RC,80299,HCPCS,,,facility,both,,,,215,161.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ustek-Ustekinumab Quant With Antibodies, Serum",3018029913,CDM,301,RC,80299,HCPCS,,,facility,both,,,,215,161.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fgaga - Quantitation Of Therapeutic Drug, Not Elsewhere Specified",3018029914,CDM,301,RC,80299,HCPCS,,,facility,both,,,,206,154.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fgaga - Quantitation Of Therapeutic Drug, Not Elsewhere Specified",3018029914,CDM,301,RC,80299,HCPCS,,,facility,both,,,,206,154.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw80-Quantitation Drug Not Elsewhere Specified,3018029915,CDM,301,RC,80299,HCPCS,,,facility,both,,,,164,123,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw80-Quantitation Drug Not Elsewhere Specified,3018029915,CDM,301,RC,80299,HCPCS,,,facility,both,,,,164,123,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Nicotine Screen, Urine",3018030501,CDM,301,RC,80305,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Nicotine Screen, Urine",3018030501,CDM,301,RC,80305,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Nicotine Screen, Urine",3018030501,CDM,301,RC,80305,HCPCS,,,facility,both,,,,13.86,10.4,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Tox Screen (Poc),3018030502,CDM,301,RC,80305,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Urine Drug Screen Rapid,3018030701,CDM,301,RC,80307,HCPCS,,,facility,both,,,,500,375,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Urine Drug Screen Rapid,3018030701,CDM,301,RC,80307,HCPCS,,,facility,both,,,,153,114.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Urine Drug Screen Rapid,3018030701,CDM,301,RC,80307,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cdau-Drug Abuse W/Confrm,Urine (Ref Lab)",3018030702,CDM,301,RC,80307,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cdau-Drug Abuse W/Confrm,Urine (Ref Lab)",3018030702,CDM,301,RC,80307,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Drug Scrn,Prescript/Otc, Serum (Ref Lab)",3018030703,CDM,301,RC,80307,HCPCS,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Drug Scrn,Prescript/Otc, Serum (Ref Lab)",3018030703,CDM,301,RC,80307,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Drug Abuse Confirm,Pnl 9,Urine (Ref Lab)",3018030704,CDM,301,RC,80307,HCPCS,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Drug Abuse Confirm,Pnl 9,Urine (Ref Lab)",3018030704,CDM,301,RC,80307,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Comprehensiv Drug Scrn,Umb Crd (Ref Lab)",3018030705,CDM,301,RC,80307,HCPCS,,,facility,both,,,,267,200.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Comprehensiv Drug Scrn,Umb Crd (Ref Lab)",3018030705,CDM,301,RC,80307,HCPCS,,,facility,both,,,,267,200.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Drugs Screen 5, Coc, Meconium (Ref Lab)",3018030706,CDM,301,RC,80307,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drug Screen 1 (Ref Lab),3018030707,CDM,301,RC,80307,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drug Screen 2 (Ref Lab),3018030708,CDM,301,RC,80307,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drug Screen 3 (Ref Lab),3018030709,CDM,301,RC,80307,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drug Screen 4 (Ref Lab),3018030710,CDM,301,RC,80307,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drug Screen 5 (Ref Lab),3018030711,CDM,301,RC,80307,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kratom (Mitragynine) Quant (Ref Lab),3018030712,CDM,301,RC,80307,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cannabinoid Analysis, Whole Bl (Ref Lab)",3018030713,CDM,301,RC,80307,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Enzyme Linked Immunosorb Assay (Ref Lab),3018030714,CDM,301,RC,80307,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Headspace Gas Chromatography (Ref Lab),3018030715,CDM,301,RC,80307,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugs Of Abuse Screen (10 Pnl) (Ref Lab),3018030716,CDM,301,RC,80307,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mephedrone, Mdpv & Methylone (Ref Lab)",3018030717,CDM,301,RC,80307,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mephedrone, Mdpv & Methylone (Ref Lab)",3018030717,CDM,301,RC,80307,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ethyl Glucuronide Screen, Random, Urine (Ref Lab)",3018030718,CDM,301,RC,80307,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ethyl Glucuronide Screen, Random, Urine (Ref Lab)",3018030718,CDM,301,RC,80307,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Drug Abuse Survey With Confirmation, Panel 5, Random, Urine (Ref Lab)",3018030719,CDM,301,RC,80307,HCPCS,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Drug Abuse Survey With Confirmation, Panel 5, Random, Urine (Ref Lab)",3018030719,CDM,301,RC,80307,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fda1S-Drugs Of Abuse (10 Panel) And Alcohol Screen, Serum",3018030721,CDM,301,RC,80307,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fda1S-Drugs Of Abuse (10 Panel) And Alcohol Screen, Serum",3018030721,CDM,301,RC,80307,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Cdau-Confirmed Drug Abuse Panel, Urine",3018030722,CDM,301,RC,80307,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cdau-Confirmed Drug Abuse Panel, Urine",3018030722,CDM,301,RC,80307,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fenr-Fentanyl Screen W/Reflex, Urine",3018030723,CDM,301,RC,80307,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fenr-Fentanyl Screen W/Reflex, Urine",3018030723,CDM,301,RC,80307,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Csmeu- Testing For Presence Of Drug, By Chemistry Analyzers",3018030724,CDM,301,RC,80307,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Csmeu- Testing For Presence Of Drug, By Chemistry Analyzers",3018030724,CDM,301,RC,80307,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Csmpu - Drug Tst Prsmv Instrmnt Chem Analyzers Pr Dat,3018030725,CDM,301,RC,80307,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Csmpu - Drug Tst Prsmv Instrmnt Chem Analyzers Pr Dat,3018030725,CDM,301,RC,80307,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Alcohol, Blood, Medical",3018032001,CDM,301,RC,80320,HCPCS,,,facility,both,,,,176,132,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Alcohol, Blood, Medical",3018032001,CDM,301,RC,80320,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Alcohol, Blood, Medical",3018032001,CDM,301,RC,80320,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Volatile Screen, Serum (Ref Lab)",3018032002,CDM,301,RC,80320,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Volatile Screen, Serum (Ref Lab)",3018032002,CDM,301,RC,80320,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ethylene Glycol (Ref Lab),3018032003,CDM,301,RC,80320,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ethylene Glycol (Ref Lab),3018032003,CDM,301,RC,80320,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Etoh-Ethanol, Urine",3018032004,CDM,301,RC,80320,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Etoh-Ethanol, Urine",3018032004,CDM,301,RC,80320,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Etgu-Ethyl Glucuronide/Sulfate (Ref Lab),3018032101,CDM,301,RC,80321,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ethyl Glucuronide Confirm, U (Ref Lab)",3018032102,CDM,301,RC,80321,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ethyl Glucuronide Confirm, U (Ref Lab)",3018032102,CDM,301,RC,80321,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ffpet-Phosphatidylethanol, Whole Blood",3018032103,CDM,301,RC,80321,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ffpet-Phosphatidylethanol, Whole Blood",3018032103,CDM,301,RC,80321,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Nicotine & Metabolites, Ur (Ref Lab)",3018032301,CDM,301,RC,80323,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Nicotine & Metabolites, Ur (Ref Lab)",3018032301,CDM,301,RC,80323,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Nicotine And Metabolites, S (Ref Lab)",3018032302,CDM,301,RC,80323,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Nicotine And Metabolites, S (Ref Lab)",3018032302,CDM,301,RC,80323,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Amphetamine Immunoassay Screen (Ref Lab),3018032401,CDM,301,RC,80324,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Amphetamines D/L Diff, Urine (Ref Lab)",3018032402,CDM,301,RC,80324,HCPCS,,,facility,both,,,,350,262.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Amphx Drug Screen Amphetamines 1/2,3018032403,CDM,301,RC,80324,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drugscan - Drug Screen Quant Amphetamines 1 Or 2,3018032404,CDM,301,RC,80324,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan - Drug Screen Quant Amphetamines 1 Or 2,3018032404,CDM,301,RC,80324,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Amphetamines Confirmation, Random, Urine (Ref Lab)",3018032501,CDM,301,RC,80325,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Amphetamines Confirmation, Random, Urine (Ref Lab)",3018032501,CDM,301,RC,80325,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Amphu Amphetamines 3Or 4,3018032502,CDM,301,RC,80325,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Amphu Amphetamines 3Or 4,3018032502,CDM,301,RC,80325,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Acetaminophen Level,3018032901,CDM,301,RC,80329,HCPCS,,,facility,both,,,,228,171,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Acetaminophen Level,3018032901,CDM,301,RC,80329,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Acetaminophen Level,3018032901,CDM,301,RC,80329,HCPCS,,,facility,both,,,,20.5,15.38,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Salicylate Level,3018032902,CDM,301,RC,80329,HCPCS,,,facility,both,,,,228,171,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Salicylate Level,3018032902,CDM,301,RC,80329,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Salicylate Level,3018032902,CDM,301,RC,80329,HCPCS,,,facility,both,,,,20.5,15.38,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Amytriptyline  Nortriptyline,S (Ref Lab)",3018033501,CDM,301,RC,80335,HCPCS,,,facility,both,,,,204,153,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Amytriptyline  Nortriptyline,S (Ref Lab)",3018033501,CDM,301,RC,80335,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Despr - Antidepressants, Tricyclic And Other Cyclicals; 1 Or 2",3018033502,CDM,301,RC,80335,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Despr - Antidepressants, Tricyclic And Other Cyclicals; 1 Or 2",3018033502,CDM,301,RC,80335,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Clobazam And Metabolite, Serum (Ref Lab)",3018033901,CDM,301,RC,80339,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Clobazam And Metabolite, Serum (Ref Lab)",3018033901,CDM,301,RC,80339,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bnzu Antiepileptics Nos 1-3,3018033902,CDM,301,RC,80339,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Bnzu Antiepileptics Nos 1-3,3018033902,CDM,301,RC,80339,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fbcs-Antiepileptics Not Otherwise Specified 1-3,3018033903,CDM,301,RC,80339,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Barbiturates Confirmation (Ref Lab),3018034501,CDM,301,RC,80345,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Barbiturates Confirmation (Ref Lab),3018034501,CDM,301,RC,80345,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drugscan - Drug Screening Barbiturates,3018034502,CDM,301,RC,80345,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan - Drug Screening Barbiturates,3018034502,CDM,301,RC,80345,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Benzodiazepines Confirmation (Ref Lab),3018034601,CDM,301,RC,80346,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Flunitrazepam Confirm (Ref Lab),3018034602,CDM,301,RC,80346,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Flunitrazepam Confirm (Ref Lab),3018034602,CDM,301,RC,80346,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drugscan - Drug Screening Benzodiazepines 1-12,3018034603,CDM,301,RC,80346,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan - Drug Screening Benzodiazepines 1-12,3018034603,CDM,301,RC,80346,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Benzodiazepines Confirm (Ref Lab),3018034701,CDM,301,RC,80347,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Benzodiazepines Confirm (Ref Lab),3018034701,CDM,301,RC,80347,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bnzu Benzodiazepines 13 Or More,3018034702,CDM,301,RC,80347,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Bnzu Benzodiazepines 13 Or More,3018034702,CDM,301,RC,80347,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Buprenorphine & Norbuprenor, U (Ref Lab)",3018034801,CDM,301,RC,80348,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Buprenorphine & Norbuprenor, U (Ref Lab)",3018034801,CDM,301,RC,80348,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Buprenorphine & Norbuprenor, U (Ref Lab)",3018034801,CDM,301,RC,80348,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Drugscan: Drug Screening Buprenorphine,3018034803,CDM,301,RC,80348,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan: Drug Screening Buprenorphine,3018034803,CDM,301,RC,80348,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Thcx-Carbxy-Thc Confirm, Urine (Ref Lab)",3018034901,CDM,301,RC,80349,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Thcx-Carbxy-Thc Confirm, Urine (Ref Lab)",3018034901,CDM,301,RC,80349,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Carboxy-Thc Confrim, Coc, M (Ref Lab)",3018034902,CDM,301,RC,80349,HCPCS,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Carboxy-Thc Confrim, Coc, M (Ref Lab)",3018034902,CDM,301,RC,80349,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cannabinoids Confirm (Ref Lab),3018034903,CDM,301,RC,80349,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fcbds-Cannabidiol, Serum",3018034904,CDM,301,RC,80349,HCPCS,,,facility,both,,,,374,280.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fcbds-Cannabidiol, Serum",3018034904,CDM,301,RC,80349,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Thcmx-Carboxy-Thc Confirmation, Coc, Meconium",3018034905,CDM,301,RC,80349,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Thcmx-Carboxy-Thc Confirmation, Coc, Meconium",3018034905,CDM,301,RC,80349,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drugscan - Drug Screening Cannabinoids Natural,3018034906,CDM,301,RC,80349,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan - Drug Screening Cannabinoids Natural,3018034906,CDM,301,RC,80349,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drugscan - Drug Screening Cannabinoids Natural,3018034907,CDM,301,RC,80349,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan - Drug Screening Cannabinoids Natural,3018034907,CDM,301,RC,80349,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Canabinoid Metabolites-Expand (Ref Lab),3018035201,CDM,301,RC,80352,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cocaine And Metabolite Confirmation, Chain Of Custody, Random, Urine (Ref Lab)",3018035301,CDM,301,RC,80353,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cocaine And Metabolite Confirmation, Chain Of Custody, Random, Urine (Ref Lab)",3018035301,CDM,301,RC,80353,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fents-Fentanyl, Serum",3018035401,CDM,301,RC,80354,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fents-Fentanyl, Serum",3018035401,CDM,301,RC,80354,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fentu-Fentanyl W/Metabolite Conf, Urine",3018035403,CDM,301,RC,80354,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fentu-Fentanyl W/Metabolite Conf, Urine",3018035403,CDM,301,RC,80354,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc 6-Monoacetylmorphine, Urine (6-Mam) (Ref Lab)",3018035601,CDM,301,RC,80356,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc 6-Monoacetylmorphine, Urine (6-Mam) (Ref Lab)",3018035601,CDM,301,RC,80356,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc 6-Monoacetylmorphine, Meconium (6-Mam) (Ref Lab)",3018035602,CDM,301,RC,80356,HCPCS,,,facility,both,,,,242,181.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc 6-Monoacetylmorphine, Meconium (6-Mam) (Ref Lab)",3018035602,CDM,301,RC,80356,HCPCS,,,facility,both,,,,242,181.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Heroin Metabolite (Ref Lab),3018035603,CDM,301,RC,80356,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan: Drug Screening Heroin Metabolite,3018035604,CDM,301,RC,80356,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan: Drug Screening Heroin Metabolite,3018035604,CDM,301,RC,80356,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Drugscan: 6-Acetylmorphine Confirmation, Add'l",3018035605,CDM,301,RC,80356,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Drugscan: 6-Acetylmorphine Confirmation, Add'l",3018035605,CDM,301,RC,80356,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fofu-Opiates-Drug Screening Heroin Metabolite,Serum",3018035607,CDM,301,RC,80356,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fofu-Opiates-Drug Screening Heroin Metabolite,Serum",3018035607,CDM,301,RC,80356,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Methadone Confirmation (Ref Lab),3018035801,CDM,301,RC,80358,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Methadone Confirmation (Ref Lab),3018035801,CDM,301,RC,80358,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drugscan - Drug Screening Methadone,3018035802,CDM,301,RC,80358,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan - Drug Screening Methadone,3018035802,CDM,301,RC,80358,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Amphetamines Confirm 1 Or More (Ref Lab),3018035901,CDM,301,RC,80359,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amphetamines Confirm 1 Or More (Ref Lab),3018035901,CDM,301,RC,80359,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Amphx Methylenedioxyamphetamines,3018035902,CDM,301,RC,80359,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Amphx Methylenedioxyamphetamines,3018035902,CDM,301,RC,80359,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Amphu Methylenedioxyamphetamines,3018035903,CDM,301,RC,80359,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Amphu Methylenedioxyamphetamines,3018035903,CDM,301,RC,80359,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Famcs-Drug Screening Methylenedioxyamphetamines,3018035905,CDM,301,RC,80359,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Famcs-Drug Screening Methylenedioxyamphetamines,3018035905,CDM,301,RC,80359,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Opiates 1 Or More (Ref Lab),3018036101,CDM,301,RC,80361,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hydromorphone Confirm, Random (Ref Lab)",3018036102,CDM,301,RC,80361,HCPCS,,,facility,both,,,,145,108.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Opatu Opiates 1 Or More,3018036103,CDM,301,RC,80361,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Opatx Opiates 1 Or More,3018036104,CDM,301,RC,80361,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Opatx Opiates 1 Or More,3018036104,CDM,301,RC,80361,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Opatu-Opiate Confirmation, Urine",3018036106,CDM,301,RC,80361,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Opatu-Opiate Confirmation, Urine",3018036106,CDM,301,RC,80361,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fofu-Drug Screening Opiates 1 Or More, Serum",3018036107,CDM,301,RC,80361,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fofu-Drug Screening Opiates 1 Or More, Serum",3018036107,CDM,301,RC,80361,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Opiates Confirmation, Random, Urine (Ref Lab)",3018036201,CDM,301,RC,80362,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Opatu Opioids & Opiate Analogs 1/2,3018036202,CDM,301,RC,80362,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Opatu Opioids & Opiate Analogs 1/2,3018036202,CDM,301,RC,80362,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Opatu-Drug Screening Opioids And Opiate Analogs 1 Or 2, Urine",3018036203,CDM,301,RC,80362,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Opatu-Drug Screening Opioids And Opiate Analogs 1 Or 2, Urine",3018036203,CDM,301,RC,80362,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Tosu-Targeted Opioid Screen, Random, Urine",3018036401,CDM,301,RC,80364,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Tosu-Targeted Opioid Screen, Random, Urine",3018036401,CDM,301,RC,80364,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drug Screening Oxycodone (Ref Lab),3018036501,CDM,301,RC,80365,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Oxycodone W/Metabolite, Urine (Ref Lab)",3018036502,CDM,301,RC,80365,HCPCS,,,facility,both,,,,223,167.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Oxycodone W/Metabolite, Urine (Ref Lab)",3018036502,CDM,301,RC,80365,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Opatu Drug Screening Oxycodone,3018036503,CDM,301,RC,80365,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Opatu Drug Screening Oxycodone,3018036503,CDM,301,RC,80365,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Opatx Drug Screening Oxycodone,3018036504,CDM,301,RC,80365,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Opatx Drug Screening Oxycodone,3018036504,CDM,301,RC,80365,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Opatu- Drug Screening Oxycodone, Urine",3018036506,CDM,301,RC,80365,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Opatu- Drug Screening Oxycodone, Urine",3018036506,CDM,301,RC,80365,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fofu- Drug Screening Oxycodone, Serum",3018036508,CDM,301,RC,80365,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fofu- Drug Screening Oxycodone, Serum",3018036508,CDM,301,RC,80365,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Zolpidem (Ambien) (Ref Lab),3018036801,CDM,301,RC,80368,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Zolpidem (Ambien) (Ref Lab),3018036801,CDM,301,RC,80368,HCPCS,,,facility,both,,,,160,120,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bnzu Sedative Hypnotics,3018036802,CDM,301,RC,80368,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Bnzu Sedative Hypnotics,3018036802,CDM,301,RC,80368,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Genotyping, Varies (Ref Lab)",3018037301,CDM,301,RC,80373,HCPCS,,,facility,both,,,,132,99,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ganciclovir, Plasma",3018037501,CDM,301,RC,80375,HCPCS,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cortisol Stimulation Test,3018040001,CDM,301,RC,80400,HCPCS,,,facility,both,,,,352,264,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cortisol Stimulation Test,3018040001,CDM,301,RC,80400,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Whole Mitochondrial Genome,3018146001,CDM,301,RC,81460,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Whole Mitochondrial Genome,3018146001,CDM,301,RC,81460,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Mitop-Test For Detecting Genes Associated With Disease, Genomic Sequence, Must Include Seque",3018146002,CDM,301,RC,81460,HCPCS,,,facility,both,,,,1648,1236,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Beta Hydroxybutyrate,3018201001,CDM,301,RC,82010,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Beta Hydroxybutyrate,3018201001,CDM,301,RC,82010,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Beta Hydroxybutyrate,3018201001,CDM,301,RC,82010,HCPCS,,,facility,both,,,,27.66,20.74,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Beta Hydroxybutyrate,3018201001,CDM,301,RC,82010,HCPCS,,,facility,both,,,,8.99,6.74,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Beta-Hydroxybutyrate (Ref Lab),3018201002,CDM,301,RC,82010,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Beta-Hydroxybutyrate (Ref Lab),3018201002,CDM,301,RC,82010,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sacred Heart: Ketone Body(S) (Eg, Acetone, Acetoacetic Acid, Beta-Hydroxybutyrate); Quantitative",3018201003,CDM,301,RC,82010,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Acylcarnitines, Quant (Ref Lab)",3018201701,CDM,301,RC,82017,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Acylcarnitines, Quant (Ref Lab)",3018201701,CDM,301,RC,82017,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  C4U-C4 Acylcarnitine, Qn, U",3018201702,CDM,301,RC,82017,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  C4U-C4 Acylcarnitine, Qn, U",3018201702,CDM,301,RC,82017,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Acth-Adrenocorticotropc Horm,P (Ref Lab)",3018202401,CDM,301,RC,82024,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Acth-Adrenocorticotropc Horm,P (Ref Lab)",3018202401,CDM,301,RC,82024,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Albumin, Serum",3018204001,CDM,301,RC,82040,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Albumin, Serum",3018204001,CDM,301,RC,82040,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Albumin, Serum",3018204001,CDM,301,RC,82040,HCPCS,,,facility,both,,,,5.45,4.09,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Albumin, Serum",3018204001,CDM,301,RC,82040,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Albumin, Serum (Ref Lab)",3018204002,CDM,301,RC,82040,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Albumin, Serum (Ref Lab)",3018204002,CDM,301,RC,82040,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Albumin, Pleural Fluid",3018204003,CDM,301,RC,82040,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Albumin, Pleural Fluid",3018204003,CDM,301,RC,82040,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Sfig-Csf Igg Index Profile, Serum And Spinal Fluid",3018204004,CDM,301,RC,82040,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Sfig-Csf Igg Index Profile, Serum And Spinal Fluid",3018204004,CDM,301,RC,82040,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Albumin, Csf (Ref Lab)",3018204201,CDM,301,RC,82042,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Albumin, Csf (Ref Lab)",3018204201,CDM,301,RC,82042,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Albumin Body Fluid,3018204202,CDM,301,RC,82042,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Albumin Body Fluid,3018204202,CDM,301,RC,82042,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Albumin Body Fluid,3018204202,CDM,301,RC,82042,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Albumin Body Fluid,3018204202,CDM,301,RC,82042,HCPCS,,,facility,both,,,,5.45,4.09,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Kh Mayo  Sfig-Albumin; Other Source, Quantitative, Each Specimen",3018204203,CDM,301,RC,82042,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Sfig-Albumin; Other Source, Quantitative, Each Specimen",3018204203,CDM,301,RC,82042,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Microalbumin, Urine, Quant",3018204301,CDM,301,RC,82043,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Microalbumin, Urine, Quant",3018204301,CDM,301,RC,82043,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Microalbumin, Urine, Quant",3018204301,CDM,301,RC,82043,HCPCS,,,facility,both,,,,6.36,4.77,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Measurement Of Alcohol Level In Specimen Other Than Breath Or Urine,3018207701,CDM,301,RC,82077,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Measurement Of Alcohol Level In Specimen Other Than Breath Or Urine,3018207701,CDM,301,RC,82077,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Aldolase (Ref Lab),3018208501,CDM,301,RC,82085,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aldolase (Ref Lab),3018208501,CDM,301,RC,82085,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Aldosterone, Serum (Ref Lab)",3018208801,CDM,301,RC,82088,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Aldosterone, Serum (Ref Lab)",3018208801,CDM,301,RC,82088,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Aldosterone, Urine (Ref Lab)",3018208802,CDM,301,RC,82088,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Aldosterone, Urine (Ref Lab)",3018208802,CDM,301,RC,82088,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Alpha-1-Antitrypsin (Ref Lab),3018210301,CDM,301,RC,82103,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Alpha-1-Antitrypsin (Ref Lab),3018210301,CDM,301,RC,82103,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Alpha-1-Antitrypsin Phenotype,3018210401,CDM,301,RC,82104,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Alpha-Fetoprotein (Ref Lab),3018210501,CDM,301,RC,82105,HCPCS,,,facility,both,,,,104,78,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Alpha-Fetoprotein (Ref Lab),3018210501,CDM,301,RC,82105,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Alpha-Fetoprotein Serum,3018210502,CDM,301,RC,82105,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Alpha-Fetoprotein Serum,3018210502,CDM,301,RC,82105,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  L3Afp-Afp L3% And Total, Serum",3018210701,CDM,301,RC,82107,HCPCS,,,facility,both,,,,245,183.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  L3Afp-Afp L3% And Total, Serum",3018210701,CDM,301,RC,82107,HCPCS,,,facility,both,,,,240,180,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Aluminum Level (Ref Lab),3018210801,CDM,301,RC,82108,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aluminum Level (Ref Lab),3018210801,CDM,301,RC,82108,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Aminolevulinic Acid (Ala) (Ref Lab),3018213501,CDM,301,RC,82135,HCPCS,,,facility,both,,,,160,120,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aminolevulinic Acid (Ala) (Ref Lab),3018213501,CDM,301,RC,82135,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cystinuria Profile, Quantitative, 24 Hour, Urine (Ref Lab)",3018213601,CDM,301,RC,82136,HCPCS,,,facility,both,,,,134,100.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cystinuria Profile, Quantitative, 24 Hour, Urine (Ref Lab)",3018213601,CDM,301,RC,82136,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Cmmps-Methylmalonic Acid Pathways,3018213602,CDM,301,RC,82136,HCPCS,,,facility,both,,,,287,215.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Cmmps-Methylmalonic Acid Pathways,3018213602,CDM,301,RC,82136,HCPCS,,,facility,both,,,,287,215.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Amino Acids,Quant,Plasma,6+ (Ref Lab)",3018213901,CDM,301,RC,82139,HCPCS,,,facility,both,,,,261,195.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Amino Acids,Quant,Plasma,6+ (Ref Lab)",3018213901,CDM,301,RC,82139,HCPCS,,,facility,both,,,,261,195.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ammonia,3018214001,CDM,301,RC,82140,HCPCS,,,facility,both,,,,169,126.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ammonia,3018214001,CDM,301,RC,82140,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ammonia,3018214001,CDM,301,RC,82140,HCPCS,,,facility,both,,,,25.46,19.1,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Ammonia,3018214001,CDM,301,RC,82140,HCPCS,,,facility,both,,,,16.03,12.02,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Ammonia,3018214001,CDM,301,RC,82140,HCPCS,,,facility,both,,,,3.33,2.5,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Amonia, Urine, 24 Hour  (Ref Lab)",3018214002,CDM,301,RC,82140,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Amonia, Urine, 24 Hour  (Ref Lab)",3018214002,CDM,301,RC,82140,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ammonium, 24 Hour, Urine (Ref Lab)",3018214003,CDM,301,RC,82140,HCPCS,,,facility,both,,,,132,99,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ammonium, 24 Hour, Urine (Ref Lab)",3018214003,CDM,301,RC,82140,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Ammonia,3018214004,CDM,301,RC,82140,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Ammonia,3018214004,CDM,301,RC,82140,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Amylase,3018215001,CDM,301,RC,82150,HCPCS,,,facility,both,,,,163,122.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amylase,3018215001,CDM,301,RC,82150,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Amylase,3018215001,CDM,301,RC,82150,HCPCS,,,facility,both,,,,10.07,7.55,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Amylase,3018215001,CDM,301,RC,82150,HCPCS,,,facility,both,,,,2.17,1.63,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Amylase, Pancreatic, Serum (Ref Lab)",3018215002,CDM,301,RC,82150,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Amylase, Pancreatic, Serum (Ref Lab)",3018215002,CDM,301,RC,82150,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Amylase, Pancreatic, Serum (Ref Lab)",3018215002,CDM,301,RC,82150,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Kh Mayo  Amlpc-Amylase, Pancreatic Cyst Fluid",3018215003,CDM,301,RC,82150,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Amlpc-Amylase, Pancreatic Cyst Fluid",3018215003,CDM,301,RC,82150,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fages-Androstanediol Glucuronide (Endocrine Sciences),3018215401,CDM,301,RC,82154,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fages-Androstanediol Glucuronide (Endocrine Sciences),3018215401,CDM,301,RC,82154,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Androstenedione, Serum (Ref Lab)",3018215701,CDM,301,RC,82157,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Androstenedione, Serum (Ref Lab)",3018215701,CDM,301,RC,82157,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Angiotensin Converting Enzyme (Ref Lab),3018216401,CDM,301,RC,82164,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angiotensin Converting Enzyme (Ref Lab),3018216401,CDM,301,RC,82164,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Angiotensin Convert Enz, Csf (Ref Lab)",3018216402,CDM,301,RC,82164,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Angiotensin Convert Enz, Csf (Ref Lab)",3018216402,CDM,301,RC,82164,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Apolipoprotein B (Ref Lab),3018217201,CDM,301,RC,82172,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Apolipoprotein B (Ref Lab),3018217201,CDM,301,RC,82172,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Apolipoprotein A1, Plasma (Ref Lab)",3018217202,CDM,301,RC,82172,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Apolipoprotein A1, Plasma (Ref Lab)",3018217202,CDM,301,RC,82172,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Apolipoprotein B, Plasma (Ref Lab)",3018217203,CDM,301,RC,82172,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Apoab Assay Of Apolipoprotein,3018217204,CDM,301,RC,82172,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Apoab Assay Of Apolipoprotein,3018217204,CDM,301,RC,82172,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Apoab Assay Of Apolipoprotein,3018217205,CDM,301,RC,82172,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Apoab Assay Of Apolipoprotein,3018217205,CDM,301,RC,82172,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Lmpp-Apolipoprotein B, S",3018217206,CDM,301,RC,82172,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Lmpp-Apolipoprotein B, S",3018217206,CDM,301,RC,82172,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Crmp1-Apolipoprotein, Each",3018217208,CDM,301,RC,82172,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arsenic (Ref Lab),3018217501,CDM,301,RC,82175,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arsenic (Ref Lab),3018217501,CDM,301,RC,82175,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Hmdb Assay Of Arsenic,3018217502,CDM,301,RC,82175,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hmdb Assay Of Arsenic,3018217502,CDM,301,RC,82175,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hmu24-Assay Of Arsenic,3018217504,CDM,301,RC,82175,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Hmu24-Assay Of Arsenic,3018217504,CDM,301,RC,82175,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Vitc-Ascorbic Acid (Vit C), Plasma",3018218001,CDM,301,RC,82180,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Vitc-Ascorbic Acid (Vit C), Plasma",3018218001,CDM,301,RC,82180,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Beta-2-Microglobulin (Ref Lab),3018223201,CDM,301,RC,82232,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Beta-2-Microglobulin (Ref Lab),3018223201,CDM,301,RC,82232,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo B2Mu-Beta-2 Microglobulin, Random, Urine",3018223202,CDM,301,RC,82232,HCPCS,,,facility,both,,,,199,149.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo B2Mu-Beta-2 Microglobulin, Random, Urine",3018223202,CDM,301,RC,82232,HCPCS,,,facility,both,,,,199,149.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bile Acids, Total, Serum (Ref Lab)",3018223901,CDM,301,RC,82239,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bile Acids, Total, Serum (Ref Lab)",3018223901,CDM,301,RC,82239,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bilirubin, Total",3018224701,CDM,301,RC,82247,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bilirubin, Total",3018224701,CDM,301,RC,82247,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bilirubin, Total",3018224701,CDM,301,RC,82247,HCPCS,,,facility,both,,,,5.52,4.14,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Bilirubin, Total",3018224701,CDM,301,RC,82247,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Neonate Chem Tbil,3018224702,CDM,301,RC,82247,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Chem Tbil,3018224702,CDM,301,RC,82247,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neonate Chem Tbil,3018224702,CDM,301,RC,82247,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Kh Bilirubin, Direct",3018224703,CDM,301,RC,82247,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Bilirubin, Direct",3018224703,CDM,301,RC,82247,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Bfbl-Bilirubin, Body Fluid",3018224704,CDM,301,RC,82247,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Bfbl-Bilirubin, Body Fluid",3018224704,CDM,301,RC,82247,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bilirubin, Direct",3018224801,CDM,301,RC,82248,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bilirubin, Direct",3018224801,CDM,301,RC,82248,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bilirubin, Direct",3018224801,CDM,301,RC,82248,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Bilirubin, Direct",3018224801,CDM,301,RC,82248,HCPCS,,,facility,both,,,,5.52,4.14,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Bilirubin, Direct",3018224801,CDM,301,RC,82248,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Neonate Chem Dbil,3018224802,CDM,301,RC,82248,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Chem Dbil,3018224802,CDM,301,RC,82248,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neonate Chem Dbil,3018224802,CDM,301,RC,82248,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Bilirubin, Direct, S (Ref Lab)",3018224803,CDM,301,RC,82248,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bilirubin, Direct, S (Ref Lab)",3018224803,CDM,301,RC,82248,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Bilirubin, Total",3018224804,CDM,301,RC,82248,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Bilirubin, Total",3018224804,CDM,301,RC,82248,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Occult Blood Feces Tc,3018227001,CDM,301,RC,82270,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Blood, Occult, Other Source",3018227101,CDM,301,RC,82271,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Blood, Occult, Other Source",3018227101,CDM,301,RC,82271,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Blood, Occult, Other Source",3018227101,CDM,301,RC,82271,HCPCS,,,facility,both,,,,5.85,4.39,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Blood,Occult,Feces",3018227401,CDM,301,RC,82274,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Blood,Occult,Feces",3018227401,CDM,301,RC,82274,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Blood,Occult,Feces",3018227401,CDM,301,RC,82274,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Test For Blood Feces Poc,3018227402,CDM,301,RC,82274,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Blood Occult Fecal Tc Poc,3018227403,CDM,301,RC,82274,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Blood Occult Fecal Tc Poc,3018227403,CDM,301,RC,82274,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Blood Occult Fecal Tc Poc,3018227403,CDM,301,RC,82274,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cadmium (Ref Lab),3018230001,CDM,301,RC,82300,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cadmium (Ref Lab),3018230001,CDM,301,RC,82300,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Hmdb Assay Of Cadmium,3018230002,CDM,301,RC,82300,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hmdb Assay Of Cadmium,3018230002,CDM,301,RC,82300,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hmu24-Assay Of Cadmium,3018230003,CDM,301,RC,82300,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Hmu24-Assay Of Cadmium,3018230003,CDM,301,RC,82300,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vitamin D 25 Hydroxy,3018230601,CDM,301,RC,82306,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vitamin D 25 Hydroxy,3018230601,CDM,301,RC,82306,HCPCS,,,facility,both,,,,131.93,98.95,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Vitamin D 25 Hydroxy,3018230601,CDM,301,RC,82306,HCPCS,,,facility,both,,,,8.98,6.74,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Vitamin D 25 Hydroxy,3018230601,CDM,301,RC,82306,HCPCS,,,facility,both,,,,44.67,33.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Vitamin D2,D3 By Lc-Ms/Ms (Ref Lab)",3018230602,CDM,301,RC,82306,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vitamin D2,D3 By Lc-Ms/Ms (Ref Lab)",3018230602,CDM,301,RC,82306,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Calcitonin, Serum (Ref Lab)",3018230801,CDM,301,RC,82308,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calcitonin, Serum (Ref Lab)",3018230801,CDM,301,RC,82308,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Calcium, Total",3018231001,CDM,301,RC,82310,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calcium, Total",3018231001,CDM,301,RC,82310,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Calcium, Total",3018231001,CDM,301,RC,82310,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Calcium, Total",3018231001,CDM,301,RC,82310,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Calcium, Ionized Poc",3018233001,CDM,301,RC,82330,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calcium, Ionized Poc",3018233001,CDM,301,RC,82330,HCPCS,,,facility,both,,,,15.05,11.29,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Ionized Calcium, Poc",3018233002,CDM,301,RC,82330,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calcium, Urine, Quant.",3018234001,CDM,301,RC,82340,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calcium, Urine, Quant.",3018234001,CDM,301,RC,82340,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Calcium, Urine, Quant.",3018234001,CDM,301,RC,82340,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Calcium, Urine, Quant.",3018234001,CDM,301,RC,82340,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Calcium, 24 Hour, Urine (Ref Lab)",3018234002,CDM,301,RC,82340,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Calcium In Urine,3018234003,CDM,301,RC,82340,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Calcium In Urine,3018234003,CDM,301,RC,82340,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Casa - Kidney Stone Analysis (Ref Lab),3018236501,CDM,301,RC,82365,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Casa - Kidney Stone Analysis (Ref Lab),3018236501,CDM,301,RC,82365,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Cdta-Carb Def Transferrin, Adult, S",3018237301,CDM,301,RC,82373,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cdta-Carb Def Transferrin, Adult, S",3018237301,CDM,301,RC,82373,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hco3 Bicarbonate,3018237401,CDM,301,RC,82374,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hco3 Bicarbonate,3018237401,CDM,301,RC,82374,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hco3 Bicarbonate,3018237401,CDM,301,RC,82374,HCPCS,,,facility,both,,,,7.37,5.53,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Hco3 Bicarbonate,3018237401,CDM,301,RC,82374,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Bicarbonate, Urine (Ref Lab)",3018237402,CDM,301,RC,82374,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Carboxyhemoglobin, Quant",3018237501,CDM,301,RC,82375,HCPCS,,,facility,both,,,,174,130.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Carboxyhemoglobin, Quant",3018237501,CDM,301,RC,82375,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Carboxyhemoglobin, Quant",3018237501,CDM,301,RC,82375,HCPCS,,,facility,both,,,,45.49,34.12,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Carboxyhemoglobin, Quant",3018237501,CDM,301,RC,82375,HCPCS,,,facility,both,,,,13.55,10.16,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cohbb - Carbon Monoxide, Blood (Ref Lab)",3018237502,CDM,301,RC,82375,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cohbb - Carbon Monoxide, Blood (Ref Lab)",3018237502,CDM,301,RC,82375,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fcmeb-Carboxyhemoglobin Quantitative,3018237503,CDM,301,RC,82375,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fcmeb-Carboxyhemoglobin Quantitative,3018237503,CDM,301,RC,82375,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Carcinoembryonic Antigen,3018237801,CDM,301,RC,82378,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Carcinoembryonic Antigen,3018237801,CDM,301,RC,82378,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Carcinoembryonic Antigen,3018237801,CDM,301,RC,82378,HCPCS,,,facility,both,,,,14.11,10.58,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Carcinoembryonic Antigen,3018237801,CDM,301,RC,82378,HCPCS,,,facility,both,,,,20.86,15.64,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Carcinoembryonic Antigen (Cea) (Ref Lab),3018237802,CDM,301,RC,82378,HCPCS,,,facility,both,,,,154,115.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Carcinoembryonic Antigen (Cea) (Ref Lab),3018237802,CDM,301,RC,82378,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Carcinoembryonic Antigen (Cea) (Ref Lab),3018237802,CDM,301,RC,82378,HCPCS,,,facility,both,,,,100.66,75.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Mayo Ceapt-Carcinoembryonic Antigen (Cea),3018237803,CDM,301,RC,82378,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ceapt-Carcinoembryonic Antigen (Cea),3018237803,CDM,301,RC,82378,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Carnitine, Total & Free (Ref Lab)",3018237901,CDM,301,RC,82379,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Carnitine, Total & Free (Ref Lab)",3018237901,CDM,301,RC,82379,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fcaro-Carotene, Beta",3018238002,CDM,301,RC,82380,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fcaro-Carotene, Beta",3018238002,CDM,301,RC,82380,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fcaro-Carotene, Beta",3018238003,CDM,301,RC,82380,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fcaro-Carotene, Beta",3018238003,CDM,301,RC,82380,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Catecholamine Frac Free 24H Ur (Ref Lab),3018238401,CDM,301,RC,82384,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Catecholamine Frac Free 24H Ur (Ref Lab),3018238401,CDM,301,RC,82384,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Catecholamine Fractionation, Free, Plasma (Ref Lab)",3018238402,CDM,301,RC,82384,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Catecholamine Fractionation, Free, Plasma (Ref Lab)",3018238402,CDM,301,RC,82384,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup: Catecholamines Fractionated,3018238404,CDM,301,RC,82384,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup: Catecholamines Fractionated,3018238404,CDM,301,RC,82384,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ceruloplasmin (Ref Lab),3018239001,CDM,301,RC,82390,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ceruloplasmin (Ref Lab),3018239001,CDM,301,RC,82390,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cholesterol, Fluid",3018239701,CDM,301,RC,82397,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cholesterol, Fluid",3018239701,CDM,301,RC,82397,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cholesterol, Fluid",3018239701,CDM,301,RC,82397,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Cholesterol, Fluid",3018239701,CDM,301,RC,82397,HCPCS,,,facility,both,,,,15.53,11.65,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Vedolizumab Ab, S (Ref Lab)",3018239702,CDM,301,RC,82397,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Infliximab Ab, S (Ref Lab)",3018239703,CDM,301,RC,82397,HCPCS,,,facility,both,,,,169,126.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Parathyroid Horm Related Peptide (Ref Lab),3018239704,CDM,301,RC,82397,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Parathyroid Horm Related Peptide (Ref Lab),3018239704,CDM,301,RC,82397,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Icam-1 (Outside Ref Lab),3018239705,CDM,301,RC,82397,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vcam-1 (Outside Ref Lab),3018239706,CDM,301,RC,82397,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vegf (Outside Ref Lab),3018239707,CDM,301,RC,82397,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Saa (Outside Ref Lab),3018239708,CDM,301,RC,82397,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Apgh-Alpha-Subunit Pituitary Tumor Marker,3018239709,CDM,301,RC,82397,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Apgh-Alpha-Subunit Pituitary Tumor Marker,3018239709,CDM,301,RC,82397,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Hmgcr-3-Hydroxy-3-Methylglutaryl Coenzyme-A (Hmg-Coa) Reductase, Serum",3018239710,CDM,301,RC,82397,HCPCS,,,facility,both,,,,281,210.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Hmgcr-3-Hydroxy-3-Methylglutaryl Coenzyme-A (Hmg-Coa) Reductase, Serum",3018239710,CDM,301,RC,82397,HCPCS,,,facility,both,,,,281,210.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Apgh-Alpha-Subunit Pituitary Tumor Marker,3018239711,CDM,301,RC,82397,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Apgh-Alpha-Subunit Pituitary Tumor Marker,3018239711,CDM,301,RC,82397,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Nms1-Analysis Using Chemiluminescent Technique (Light And Chemical )Reaction,3018239712,CDM,301,RC,82397,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Nms1-Analysis Using Chemiluminescent Technique (Light And Chemical )Reaction,3018239712,CDM,301,RC,82397,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fgaga - Chemiluminescent Assay,3018239713,CDM,301,RC,82397,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fgaga - Chemiluminescent Assay,3018239713,CDM,301,RC,82397,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Vemab - Chemiluminescent Assay,3018239714,CDM,301,RC,82397,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Vemab - Chemiluminescent Assay,3018239714,CDM,301,RC,82397,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Chloride, Poc",3018243501,CDM,301,RC,82435,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chloride,3018243502,CDM,301,RC,82435,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chloride,3018243502,CDM,301,RC,82435,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chloride,3018243502,CDM,301,RC,82435,HCPCS,,,facility,both,,,,6.94,5.2,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Chloride, Urine",3018243601,CDM,301,RC,82436,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Chloride, Urine",3018243601,CDM,301,RC,82436,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Chloride, Urine",3018243601,CDM,301,RC,82436,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Chloride, Urine, 24 Hour (Ref Lab)",3018243602,CDM,301,RC,82436,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sup24 Assay Of Urine Chloride,3018243603,CDM,301,RC,82436,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sup24 Assay Of Urine Chloride,3018243603,CDM,301,RC,82436,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Chloride, F (Ref Lab)",3018243801,CDM,301,RC,82438,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Chloride, F (Ref Lab)",3018243801,CDM,301,RC,82438,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Efpo Assay Other Fluid Chlorides,3018243802,CDM,301,RC,82438,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Efpo Assay Other Fluid Chlorides,3018243802,CDM,301,RC,82438,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cholesterol, Serum, Total",3018246501,CDM,301,RC,82465,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cholesterol, Serum, Total",3018246501,CDM,301,RC,82465,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cholesterol, Serum, Total",3018246501,CDM,301,RC,82465,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cholesterol, Serum, Total",3018246501,CDM,301,RC,82465,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Kh Mayo  Lmpp-Cholesterol, Total, Cdc, S",3018246502,CDM,301,RC,82465,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Lmpp-Cholesterol, Total, Cdc, S",3018246502,CDM,301,RC,82465,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Crmp1-Cholesterol, Serum Or Whole Blood, Total",3018246503,CDM,301,RC,82465,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Pche1-Cholinesterase Serum,3018248001,CDM,301,RC,82480,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Chromium, Blood (Ref Lab)",3018249501,CDM,301,RC,82495,HCPCS,,,facility,both,,,,358,268.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Citrate Excretion, 24 Hour, Urine (Ref Lab)",3018250701,CDM,301,RC,82507,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Citrate Excretion, 24 Hour, Urine (Ref Lab)",3018250701,CDM,301,RC,82507,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Citrate, Urine, 24 Hour (Ref Lab)",3018250702,CDM,301,RC,82507,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Citrate, Urine, 24 Hour (Ref Lab)",3018250702,CDM,301,RC,82507,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Citrate,3018250703,CDM,301,RC,82507,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Citrate,3018250703,CDM,301,RC,82507,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ntx-Telopeptide, Urine (Ref Lab)",3018252301,CDM,301,RC,82523,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ntx-Telopeptide, Urine (Ref Lab)",3018252301,CDM,301,RC,82523,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ntxpr Collagen Crosslinks,3018252302,CDM,301,RC,82523,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ntxpr Collagen Crosslinks,3018252302,CDM,301,RC,82523,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ctx-Beta-Crosslaps (B-Ctx), Serum",3018252303,CDM,301,RC,82523,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ctx-Beta-Crosslaps (B-Ctx), Serum",3018252303,CDM,301,RC,82523,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Sntx-Ntx-Telopeptide, Serum",3018252304,CDM,301,RC,82523,HCPCS,,,facility,both,,,,195,146.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Sntx-Ntx-Telopeptide, Serum",3018252304,CDM,301,RC,82523,HCPCS,,,facility,both,,,,195,146.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Copper/Creat Ratio, U (Ref Lab)",3018252501,CDM,301,RC,82525,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Copper/Creat Ratio, U (Ref Lab)",3018252501,CDM,301,RC,82525,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Copper 24Hr, Urine (Ref Lab)",3018252502,CDM,301,RC,82525,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Copper 24Hr, Urine (Ref Lab)",3018252502,CDM,301,RC,82525,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fcopp-Copper, Rbc",3018252503,CDM,301,RC,82525,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fcopp-Copper, Rbc",3018252503,CDM,301,RC,82525,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Cus1-Copper, Serum",3018252504,CDM,301,RC,82525,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Cus1-Copper, Serum",3018252504,CDM,301,RC,82525,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Curcu-Assay Of Copper,3018252506,CDM,301,RC,82525,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cut-Assay Of Copper,3018252507,CDM,301,RC,82525,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cut-Assay Of Copper,3018252507,CDM,301,RC,82525,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cortisol, Free, 24 Hour, Urine (Ref Lab)",3018253001,CDM,301,RC,82530,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cortisol, Free, 24 Hour, Urine (Ref Lab)",3018253001,CDM,301,RC,82530,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cortisol/Cortisone, Free, 24 Hour, Urine (Ref Lab)",3018253002,CDM,301,RC,82530,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cortisol/Cortisone, Free, 24 Hour, Urine (Ref Lab)",3018253002,CDM,301,RC,82530,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cocou Cortisol Free,3018253003,CDM,301,RC,82530,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cocou Cortisol Free,3018253003,CDM,301,RC,82530,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Cortf-Cortisol, Free, Serum",3018253005,CDM,301,RC,82530,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Cortf-Cortisol, Free, Serum",3018253005,CDM,301,RC,82530,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cortisol, Total",3018253301,CDM,301,RC,82533,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cortisol, Total",3018253301,CDM,301,RC,82533,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cortisol, Total",3018253301,CDM,301,RC,82533,HCPCS,,,facility,both,,,,13.73,10.3,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Cortisol, Total",3018253301,CDM,301,RC,82533,HCPCS,,,facility,both,,,,17.93,13.45,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cortisol, Add Stim Spec",3018253302,CDM,301,RC,82533,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cortisol, Add Stim Spec",3018253302,CDM,301,RC,82533,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cortisol, Pre-Dexamethasone",3018253303,CDM,301,RC,82533,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cortisol, Pre-Dexamethasone",3018253303,CDM,301,RC,82533,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cortisol, Pre-Dexamethasone",3018253303,CDM,301,RC,82533,HCPCS,,,facility,both,,,,17.93,13.45,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cortisol, Post-Dexamethasone",3018253304,CDM,301,RC,82533,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cortisol, Post-Dexamethasone",3018253304,CDM,301,RC,82533,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cortisol, Post-Dexamethasone",3018253304,CDM,301,RC,82533,HCPCS,,,facility,both,,,,17.93,13.45,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Lte4 Leukotriene E4, Urine (Ref Lab)",3018254201,CDM,301,RC,82542,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lte4 Leukotriene E4, Urine (Ref Lab)",3018254201,CDM,301,RC,82542,HCPCS,,,facility,both,,,,262,196.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Baps-Bile Acid Profile, Serum (Ref Lab)",3018254202,CDM,301,RC,82542,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Baps-Bile Acid Profile, Serum (Ref Lab)",3018254202,CDM,301,RC,82542,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Fatty Acid Profl,Essent,Plasma (Ref Lab)",3018254203,CDM,301,RC,82542,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fatty Acid Profl,Essent,Plasma (Ref Lab)",3018254203,CDM,301,RC,82542,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pyridoxic Acid (Pa) B6 (Ref Lab),3018254204,CDM,301,RC,82542,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pyridoxic Acid (Pa) B6 (Ref Lab),3018254204,CDM,301,RC,82542,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc N-Methylhistamine, 24 Hr,Urine (Ref Lab)",3018254205,CDM,301,RC,82542,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc N-Methylhistamine, 24 Hr,Urine (Ref Lab)",3018254205,CDM,301,RC,82542,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coenzyme Q10, Total, Plasma (Ref Lab)",3018254206,CDM,301,RC,82542,HCPCS,,,facility,both,,,,142,106.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fatty Acid Profl, Comprehen, P (Ref Lab)",3018254207,CDM,301,RC,82542,HCPCS,,,facility,both,,,,134,100.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Col Chromotography Qual/Quan (Ref Lab),3018254208,CDM,301,RC,82542,HCPCS,,,facility,both,,,,283,212.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc 6-Methyl-Thioguanine,Qnt Hplc (Outside Ref Lab)",3018254209,CDM,301,RC,82542,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cocou Col Chromotography Qual/Quan,3018254210,CDM,301,RC,82542,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cocou Col Chromotography Qual/Quan,3018254210,CDM,301,RC,82542,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo B6Pro Col Chromotography Qual/Quan,3018254211,CDM,301,RC,82542,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo B6Pro Col Chromotography Qual/Quan,3018254211,CDM,301,RC,82542,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Hex4-Glucotetrasaccharides, Random, Urine",3018254212,CDM,301,RC,82542,HCPCS,,,facility,both,,,,390,292.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Hex4-Glucotetrasaccharides, Random, Urine",3018254212,CDM,301,RC,82542,HCPCS,,,facility,both,,,,390,292.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Srau-Serotonin Release Assay, Unfractionated Heparin, Mass Spectrometry, Serum",3018254213,CDM,301,RC,82542,HCPCS,,,facility,both,,,,416,312,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Srau-Serotonin Release Assay, Unfractionated Heparin, Mass Spectrometry, Serum",3018254213,CDM,301,RC,82542,HCPCS,,,facility,both,,,,416,312,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Pupyu-Purines And Pyrimidines, Urine",3018254214,CDM,301,RC,82542,HCPCS,,,facility,both,,,,209,156.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Pupyu-Purines And Pyrimidines, Urine",3018254214,CDM,301,RC,82542,HCPCS,,,facility,both,,,,209,156.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  F2Iso-F2-Isoprostanes, Random, Urine",3018254215,CDM,301,RC,82542,HCPCS,,,facility,both,,,,290,217.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  F2Iso-F2-Isoprostanes, Random, Urine",3018254215,CDM,301,RC,82542,HCPCS,,,facility,both,,,,290,217.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Meta3-Chemical Analysis Using Chromatography Technique,3018254216,CDM,301,RC,82542,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Meta3-Chemical Analysis Using Chromatography Technique,3018254216,CDM,301,RC,82542,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Bafs-Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec,3018254217,CDM,301,RC,82542,HCPCS,,,facility,both,,,,171,128.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Msptc-Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec,3018254218,CDM,301,RC,82542,HCPCS,,,facility,both,,,,239,179.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Pgrbc - Chemical Analysis Using Chromatography Technique,3018254219,CDM,301,RC,82542,HCPCS,,,facility,both,,,,388,291,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Pgrbc - Chemical Analysis Using Chromatography Technique,3018254219,CDM,301,RC,82542,HCPCS,,,facility,both,,,,388,291,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Pipa - Chemical Analysis Using Chromatography Technique,3018254220,CDM,301,RC,82542,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Pipa - Chemical Analysis Using Chromatography Technique,3018254220,CDM,301,RC,82542,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Baipd - Chemical Analysis Using Chromatography Technique,3018254221,CDM,301,RC,82542,HCPCS,,,facility,both,,,,336,252,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Baipd - Chemical Analysis Using Chromatography Technique,3018254221,CDM,301,RC,82542,HCPCS,,,facility,both,,,,336,252,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ppfe-Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec,3018254222,CDM,301,RC,82542,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ppfe-Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec,3018254222,CDM,301,RC,82542,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo A1Alc-Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec,3018254223,CDM,301,RC,82542,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo A1Alc-Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec,3018254223,CDM,301,RC,82542,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Lpcbs-Chemical Analysis Using Chromatography Technique,3018254224,CDM,301,RC,82542,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Lpcbs-Chemical Analysis Using Chromatography Technique,3018254224,CDM,301,RC,82542,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Creatine Kinase, Total",3018255001,CDM,301,RC,82550,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Creatine Kinase, Total",3018255001,CDM,301,RC,82550,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Creatine Kinase, Total",3018255001,CDM,301,RC,82550,HCPCS,,,facility,both,,,,7.75,5.81,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Creatine Kinase, Total",3018255001,CDM,301,RC,82550,HCPCS,,,facility,both,,,,7.16,5.37,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Creatine Kinase, Total",3018255001,CDM,301,RC,82550,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Creatine Kinase Isoenzyme Rflx,3018255002,CDM,301,RC,82550,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Creatine Kinase Isoenzyme Rflx,3018255002,CDM,301,RC,82550,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Creatine Kinase Isoenzymes (Ref Lab),3018255201,CDM,301,RC,82552,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Creatine Kinase Isoenzymes (Ref Lab),3018255201,CDM,301,RC,82552,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Creatinine, Blood",3018256501,CDM,301,RC,82565,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Creatinine, Blood",3018256501,CDM,301,RC,82565,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Creatinine, Blood",3018256501,CDM,301,RC,82565,HCPCS,,,facility,both,,,,26.3,19.72,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Creatinine, Blood",3018256501,CDM,301,RC,82565,HCPCS,,,facility,both,,,,7.73,5.8,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Creatinine, Blood",3018256501,CDM,301,RC,82565,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Creatinine,Blood (Poc)",3018256502,CDM,301,RC,82565,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Creatinine,Blood,Reagent Strip",3018256503,CDM,301,RC,82565,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Creatinine, Other Source",3018257001,CDM,301,RC,82570,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Creatinine, Other Source",3018257001,CDM,301,RC,82570,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Creatinine, Other Source",3018257001,CDM,301,RC,82570,HCPCS,,,facility,both,,,,7.73,5.8,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Creatinine, Other Source",3018257001,CDM,301,RC,82570,HCPCS,,,facility,both,,,,1.48,1.11,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Creatinine (Ref Lab),3018257002,CDM,301,RC,82570,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Creatinine (Ref Lab),3018257002,CDM,301,RC,82570,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Urine Creatinine (Ref Lab),3018257003,CDM,301,RC,82570,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Urine Creatinine (Ref Lab),3018257003,CDM,301,RC,82570,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ntxpr Assay Of Urine Creatinine,3018257004,CDM,301,RC,82570,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ntxpr Assay Of Urine Creatinine,3018257004,CDM,301,RC,82570,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Creatinine,3018257005,CDM,301,RC,82570,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Creatinine,3018257005,CDM,301,RC,82570,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Hex4-Creatinine; Other Source,3018257006,CDM,301,RC,82570,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Hex4-Creatinine; Other Source,3018257006,CDM,301,RC,82570,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Rmpqu/Rptu2-Creatinine, Random, Urine",3018257007,CDM,301,RC,82570,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Rmpqu/Rptu2-Creatinine, Random, Urine",3018257007,CDM,301,RC,82570,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo 23Bpr-Creatinine Other Source,3018257008,CDM,301,RC,82570,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Curcu-Assay Of Urine Creatinine,3018257009,CDM,301,RC,82570,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Creatinine Clearance,3018257501,CDM,301,RC,82575,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Creatinine Clearance,3018257501,CDM,301,RC,82575,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Creatinine Clearance,3018257501,CDM,301,RC,82575,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc  Cryofibrinogen, Plasma (Ref Lab)",3018258501,CDM,301,RC,82585,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc  Cryofibrinogen, Plasma (Ref Lab)",3018258501,CDM,301,RC,82585,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Crgsp Assay Of Cryofibrinogen,3018258502,CDM,301,RC,82585,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Crgsp Assay Of Cryofibrinogen,3018258502,CDM,301,RC,82585,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cryoglobulin,3018259501,CDM,301,RC,82595,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cryoglobulin,3018259501,CDM,301,RC,82595,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cryoglobulin,3018259501,CDM,301,RC,82595,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Cryoglobulin,3018259501,CDM,301,RC,82595,HCPCS,,,facility,both,,,,7.12,5.34,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cryoglobulin, Serum (Ref Lab)",3018259502,CDM,301,RC,82595,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cryoglobulin, Serum (Ref Lab)",3018259502,CDM,301,RC,82595,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Crgsp Assay Of Cryoglobulin,3018259503,CDM,301,RC,82595,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Crgsp Assay Of Cryoglobulin,3018259503,CDM,301,RC,82595,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fcynb Assay Of Cyanide, Blood",3018260001,CDM,301,RC,82600,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-12 Level,3018260701,CDM,301,RC,82607,HCPCS,,,facility,both,,,,142,106.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-12 Level,3018260701,CDM,301,RC,82607,HCPCS,,,facility,both,,,,110.3,82.72,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc B-12 Level,3018260701,CDM,301,RC,82607,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc B-12 Level,3018260701,CDM,301,RC,82607,HCPCS,,,facility,both,,,,16.59,12.44,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc B-12 Level,3018260701,CDM,301,RC,82607,HCPCS,,,facility,both,,,,2.75,2.06,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Pernicious Anemia Cascade (Ref Lab),3018260702,CDM,301,RC,82607,HCPCS,,,facility,both,,,,127,95.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pernicious Anemia Cascade (Ref Lab),3018260702,CDM,301,RC,82607,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pernicious Anemia Cascade (Ref Lab),3018260702,CDM,301,RC,82607,HCPCS,,,facility,both,,,,16.59,12.44,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Kh Vitamin B12,3018260703,CDM,301,RC,82607,HCPCS,,,facility,both,,,,144,108,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Vitamin B12,3018260703,CDM,301,RC,82607,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cystatin C Level (Ref Lab),3018261001,CDM,301,RC,82610,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cystatin C Level (Ref Lab),3018261001,CDM,301,RC,82610,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Dehydroepiandrosterone (Dhea), Serum (Ref Lab)",3018262601,CDM,301,RC,82626,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Dehydroepiandrosterone (Dhea), Serum (Ref Lab)",3018262601,CDM,301,RC,82626,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Dhea-So4 / Dhea Sulfate (Ref Lab),3018262701,CDM,301,RC,82627,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dhea-So4 / Dhea Sulfate (Ref Lab),3018262701,CDM,301,RC,82627,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Dihydrotestosterone (Ref Lab),3018264201,CDM,301,RC,82642,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dihydrotestosterone (Ref Lab),3018264201,CDM,301,RC,82642,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Vitamin D (1,25 Di-Hydroxy) (Ref Lab)",3018265201,CDM,301,RC,82652,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vitamin D (1,25 Di-Hydroxy) (Ref Lab)",3018265201,CDM,301,RC,82652,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pancreatic Elastase-1 (Ref Lab),3018265601,CDM,301,RC,82656,HCPCS,,,facility,both,,,,184,138,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Enzyme Cell Activity (Ref Lab),3018265701,CDM,301,RC,82657,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tpmt Activity Profile, Rbc (Ref Lab)",3018265702,CDM,301,RC,82657,HCPCS,,,facility,both,,,,321,240.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tpmt Activity Profile, Rbc (Ref Lab)",3018265702,CDM,301,RC,82657,HCPCS,,,facility,both,,,,321,240.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Tpmt Enzyme Activity, Rbc (Outside Ref Lab)",3018265703,CDM,301,RC,82657,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Gaaw-Acid Alpha-Glucosidase, Leukocytes",3018265704,CDM,301,RC,82657,HCPCS,,,facility,both,,,,549,411.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Gaaw-Acid Alpha-Glucosidase, Leukocytes",3018265704,CDM,301,RC,82657,HCPCS,,,facility,both,,,,549,411.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Nzym Activ Bld Cells/Tiss Nonradact Substrate Ea,3018265705,CDM,301,RC,82657,HCPCS,,,facility,both,,,,220,165,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Nzym Activ Bld Cells/Tiss Nonradact Substrate Ea,3018265705,CDM,301,RC,82657,HCPCS,,,facility,both,,,,220,165,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Alad-Enzyme Activity In Blood Cells, Cultured Cells, Or Tissue, Not Elsewhere Specified; Non",3018265706,CDM,301,RC,82657,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Pbgd_-Enzyme Activity In Blood Cells, Cultured Cells, Or Tissue, Not Elsewhere Specified; No",3018265707,CDM,301,RC,82657,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Electrophoretic Test (Ref Lab),3018266401,CDM,301,RC,82664,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Csu-Chyluria Screen, Random, Urine",3018266402,CDM,301,RC,82664,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Csu-Chyluria Screen, Random, Urine",3018266402,CDM,301,RC,82664,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Erythropoietin Level (Ref Lab),3018266801,CDM,301,RC,82668,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Erythropoietin Level (Ref Lab),3018266801,CDM,301,RC,82668,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Estradiol (Ref Lab),3018267001,CDM,301,RC,82670,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Estradiol (Ref Lab),3018267001,CDM,301,RC,82670,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ests-Estradiol,Rapid,Immun,Ser (Ref Lab)",3018267002,CDM,301,RC,82670,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ests-Estradiol,Rapid,Immun,Ser (Ref Lab)",3018267002,CDM,301,RC,82670,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Assay Of Total Estradiol,3018267003,CDM,301,RC,82670,HCPCS,,,facility,both,,,,163,122.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Assay Of Total Estradiol,3018267003,CDM,301,RC,82670,HCPCS,,,facility,both,,,,163,122.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ffes-Measurement Of Total Estradiol (Hormone),3018267004,CDM,301,RC,82670,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ffes-Measurement Of Total Estradiol (Hormone),3018267004,CDM,301,RC,82670,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Estrogens, Fractionated (Ref Lab)",3018267101,CDM,301,RC,82671,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Estrogens, Fractionated (Ref Lab)",3018267101,CDM,301,RC,82671,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Estriol, Unconjugated, Serum (Ref Lab)",3018267701,CDM,301,RC,82677,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Estriol, Unconjugated, Serum (Ref Lab)",3018267701,CDM,301,RC,82677,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Estrone (Ref Lab),3018267901,CDM,301,RC,82679,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Estrone (Ref Lab),3018267901,CDM,301,RC,82679,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ffes-Direct Measurement Of Free Estradiol (Hormone),3018268101,CDM,301,RC,82681,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ffes-Direct Measurement Of Free Estradiol (Hormone),3018268101,CDM,301,RC,82681,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Fatf - Fat, Feces (Ref Lab)",3018271001,CDM,301,RC,82710,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fatf - Fat, Feces (Ref Lab)",3018271001,CDM,301,RC,82710,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fapep-Fatty Acids Measurement,3018272501,CDM,301,RC,82725,HCPCS,,,facility,both,,,,134,100.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Pox-Fatty Acid Profile,Peroxisom",3018272601,CDM,301,RC,82726,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Pox-Fatty Acid Profile,Peroxisom",3018272601,CDM,301,RC,82726,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ferritin,3018272801,CDM,301,RC,82728,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ferritin,3018272801,CDM,301,RC,82728,HCPCS,,,facility,both,,,,102.73,77.05,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Ferritin,3018272801,CDM,301,RC,82728,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Ferritin,3018272801,CDM,301,RC,82728,HCPCS,,,facility,both,,,,14.99,11.24,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Ferritin,3018272801,CDM,301,RC,82728,HCPCS,,,facility,both,,,,1.92,1.44,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Ferritin, S (Ref Lab)",3018272802,CDM,301,RC,82728,HCPCS,,,facility,both,,,,130,97.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ferritin, S (Ref Lab)",3018272802,CDM,301,RC,82728,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fetal Fibronectin,3018273101,CDM,301,RC,82731,HCPCS,,,facility,both,,,,783,587.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fetal Fibronectin,3018273101,CDM,301,RC,82731,HCPCS,,,facility,both,,,,776,582,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fetal Fibronectin,3018273101,CDM,301,RC,82731,HCPCS,,,facility,both,,,,70.85,53.14,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Fetal Fibronectin,3018273101,CDM,301,RC,82731,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Folic Acid (Folate), Serum",3018274601,CDM,301,RC,82746,HCPCS,,,facility,both,,,,133,99.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Folic Acid (Folate), Serum",3018274601,CDM,301,RC,82746,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Folic Acid (Folate), Serum",3018274601,CDM,301,RC,82746,HCPCS,,,facility,both,,,,16.17,12.13,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Folic Acid (Folate), Serum",3018274601,CDM,301,RC,82746,HCPCS,,,facility,both,,,,4.02,3.02,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Folate, S (Ref Lab)",3018274602,CDM,301,RC,82746,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Folate, S (Ref Lab)",3018274602,CDM,301,RC,82746,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Folate,3018274603,CDM,301,RC,82746,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Folate,3018274603,CDM,301,RC,82746,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Galactose, Quantitative, Urine (Ref Lab)",3018276001,CDM,301,RC,82760,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Gal3-Galectin-3,3018277701,CDM,301,RC,82777,HCPCS,,,facility,both,,,,182,136.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Gal3-Galectin-3,3018277701,CDM,301,RC,82777,HCPCS,,,facility,both,,,,182,136.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Igg, Serum (Ref Lab)",3018278401,CDM,301,RC,82784,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Igg, Serum (Ref Lab)",3018278401,CDM,301,RC,82784,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Igg, Csf (Ref Lab)",3018278402,CDM,301,RC,82784,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunoglobulin A (Ref Lab),3018278403,CDM,301,RC,82784,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunoglobulin A (Ref Lab),3018278403,CDM,301,RC,82784,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Immunoglobulin G (Ref Lab),3018278404,CDM,301,RC,82784,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunoglobulin G (Ref Lab),3018278404,CDM,301,RC,82784,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Immunoglobulin M (Ref Lab),3018278405,CDM,301,RC,82784,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunoglobulin M (Ref Lab),3018278405,CDM,301,RC,82784,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Total Igg (Ref Lab),3018278406,CDM,301,RC,82784,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Total Igg (Ref Lab),3018278406,CDM,301,RC,82784,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Immunoglobulin A (Iga) (Ref Lab),3018278407,CDM,301,RC,82784,HCPCS,,,facility,both,,,,132,99,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunoglobulin D (Ref Lab),3018278408,CDM,301,RC,82784,HCPCS,,,facility,both,,,,104,78,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunoglobulin D (Ref Lab),3018278408,CDM,301,RC,82784,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cdcom Assay Iga/Igd/Igg/Igm Each,3018278409,CDM,301,RC,82784,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cdcom Assay Iga/Igd/Igg/Igm Each,3018278409,CDM,301,RC,82784,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Assay Of Gammaglobulin Iga Igd Igg Igm Each,3018278410,CDM,301,RC,82784,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Assay Of Gammaglobulin Iga Igd Igg Igm Each,3018278410,CDM,301,RC,82784,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Iga-Immunoglobulin A (Iga), S",3018278411,CDM,301,RC,82784,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Iga-Immunoglobulin A (Iga), S",3018278411,CDM,301,RC,82784,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Sfig-Gammaglobulin (Immunoglobulin); Iga, Igd, Igg, Igm, Each",3018278412,CDM,301,RC,82784,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Sfig-Gammaglobulin (Immunoglobulin); Iga, Igd, Igg, Igm, Each",3018278412,CDM,301,RC,82784,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Qmpss-Assay Of Gammaglobulin Iga Igd Igg Igm Each,3018278413,CDM,301,RC,82784,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Qmpss-Assay Of Gammaglobulin Iga Igd Igg Igm Each,3018278413,CDM,301,RC,82784,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fmnpp-Assay Of Gammaglobulin Iga Igd Igg Igm Each,3018278414,CDM,301,RC,82784,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fmnpp-Assay Of Gammaglobulin Iga Igd Igg Igm Each,3018278414,CDM,301,RC,82784,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Immunoglobulin E (Ref Lab),3018278501,CDM,301,RC,82785,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Immunoglobulin E, Ige (Ref Lab)",3018278502,CDM,301,RC,82785,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Immunoglobulin E, Ige (Ref Lab)",3018278502,CDM,301,RC,82785,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Assay Of Ige,3018278503,CDM,301,RC,82785,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Assay Of Ige,3018278503,CDM,301,RC,82785,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Assay Of Ige,3018278504,CDM,301,RC,82785,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Assay Of Ige,3018278504,CDM,301,RC,82785,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Assay Of Ige,3018278505,CDM,301,RC,82785,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Assay Of Ige,3018278505,CDM,301,RC,82785,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Respiratory Profile, Region 11, Rocky Mountain (Az [Mt]; Co; Id [Mt]; Nm, Ut [Mt];",3018278507,CDM,301,RC,82785,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Respiratory Profile, Region 11, Rocky Mountain (Az [Mt]; Co; Id [Mt]; Nm, Ut [Mt];",3018278507,CDM,301,RC,82785,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo-Rpr15 Assay Of Gammaglobulin Ige,3018278508,CDM,301,RC,82785,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo-Rpr15 Assay Of Gammaglobulin Ige,3018278508,CDM,301,RC,82785,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Igg Subclass 4 (Ref Lab),3018278701,CDM,301,RC,82787,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igg Subclass 4 (Ref Lab),3018278701,CDM,301,RC,82787,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Igg Subclass 1 (Ref Lab),3018278702,CDM,301,RC,82787,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igg Subclass 1 (Ref Lab),3018278702,CDM,301,RC,82787,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Igg Subclass 2 (Ref Lab),3018278703,CDM,301,RC,82787,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igg Subclass 2 (Ref Lab),3018278703,CDM,301,RC,82787,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Igg Subclass 3 (Ref Lab),3018278704,CDM,301,RC,82787,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igg Subclass 3 (Ref Lab),3018278704,CDM,301,RC,82787,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Igg Subclass 4 - Multiple (Ref Lab),3018278705,CDM,301,RC,82787,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iga 1 Subclass (Ref Lab),3018278706,CDM,301,RC,82787,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iga 2 Subclass (Ref Lab),3018278707,CDM,301,RC,82787,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Blood Gases, Ph Only",3018280001,CDM,301,RC,82800,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Blood Gases, Ph Only",3018280001,CDM,301,RC,82800,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Blood Gases, Ph Only",3018280001,CDM,301,RC,82800,HCPCS,,,facility,both,,,,12.1,9.08,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Blood Gases, Arterial Poc",3018280301,CDM,301,RC,82803,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Blood Gases, Arterial Poc",3018280301,CDM,301,RC,82803,HCPCS,,,facility,both,,,,29.19,21.89,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Blood Gases, Capillary Poc",3018280302,CDM,301,RC,82803,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Blood Gases, Cord Blood",3018280303,CDM,301,RC,82803,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Blood Gases, Cord Blood",3018280303,CDM,301,RC,82803,HCPCS,,,facility,both,,,,320,240,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Blood Gases, Cord Blood",3018280303,CDM,301,RC,82803,HCPCS,,,facility,both,,,,28.68,21.51,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Blood Gases, Venous, Mixed-Ven Poc",3018280304,CDM,301,RC,82803,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Blood Gases, Venous, Mixed-Ven Poc",3018280304,CDM,301,RC,82803,HCPCS,,,facility,both,,,,28.68,21.51,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Blood Gases Any Combination Ph Pco2 Po2 Co2 Hco3,3018280305,CDM,301,RC,82803,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gastrin (Ref Lab),3018294101,CDM,301,RC,82941,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gastrin (Ref Lab),3018294101,CDM,301,RC,82941,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Glucagon, Plasma (Ref Lab)",3018294301,CDM,301,RC,82943,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Glucagon, Plasma (Ref Lab)",3018294301,CDM,301,RC,82943,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Glucose,Quant,Body Fluid",3018294501,CDM,301,RC,82945,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Glucose,Quant,Body Fluid",3018294501,CDM,301,RC,82945,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Glucose,Quant,Body Fluid",3018294501,CDM,301,RC,82945,HCPCS,,,facility,both,,,,5.93,4.45,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Glucose, Quantitative, Blood",3018294701,CDM,301,RC,82947,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Glucose, Quantitative, Blood",3018294701,CDM,301,RC,82947,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Glucose, Quantitative, Blood",3018294701,CDM,301,RC,82947,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Glucose, Quantitative, Blood",3018294701,CDM,301,RC,82947,HCPCS,,,facility,both,,,,5.9,4.42,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Glucose, Quantitative, Blood",3018294701,CDM,301,RC,82947,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Kh Gtt Fasting,3018294702,CDM,301,RC,82947,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Gtt Fasting,3018294702,CDM,301,RC,82947,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Glucose, Blood, Reagent Strip",3018294801,CDM,301,RC,82948,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Glucose, Blood, Reagent Strip (Poc)",3018294802,CDM,301,RC,82948,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Glucose, Blood, Reagent Strip (Poc)",3018294802,CDM,301,RC,82948,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Glucose,Quant,Post Gluc Dose",3018295001,CDM,301,RC,82950,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Glucose,Quant,Post Gluc Dose",3018295001,CDM,301,RC,82950,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Glucose,Quant,Post Gluc Dose",3018295001,CDM,301,RC,82950,HCPCS,,,facility,both,,,,5.9,4.42,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Glucose,Quant,Post Gluc Dose",3018295001,CDM,301,RC,82950,HCPCS,,,facility,both,,,,2.45,1.84,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Glucose,Tol. Test;1-3 Specs",3018295101,CDM,301,RC,82951,HCPCS,,,facility,both,,,,170,127.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Glucose,Tol. Test;1-3 Specs",3018295101,CDM,301,RC,82951,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc G-6-Pd, Quant (Ref Lab)",3018295501,CDM,301,RC,82955,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc G-6-Pd, Quant (Ref Lab)",3018295501,CDM,301,RC,82955,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Gluc-6-Phosphate Dehydrogenase Quantitative,3018295503,CDM,301,RC,82955,HCPCS,,,facility,both,,,,96,72,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Gluc-6-Phosphate Dehydrogenase Quantitative,3018295503,CDM,301,RC,82955,HCPCS,,,facility,both,,,,96,72,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ggt,3018297701,CDM,301,RC,82977,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ggt,3018297701,CDM,301,RC,82977,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ggt,3018297701,CDM,301,RC,82977,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Ggt,3018297701,CDM,301,RC,82977,HCPCS,,,facility,both,,,,8.24,6.18,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Ggt,3018297701,CDM,301,RC,82977,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Kh Mayo  Ggt-Ggt, Serum",3018297702,CDM,301,RC,82977,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ggt-Ggt, Serum",3018297702,CDM,301,RC,82977,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Gsh-Glutathione, Blood",3018297801,CDM,301,RC,82978,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Gsh-Glutathione, Blood",3018297801,CDM,301,RC,82978,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Assay Of Glutathione,3018297802,CDM,301,RC,82978,HCPCS,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Assay Of Glutathione,3018297802,CDM,301,RC,82978,HCPCS,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fructosamine (Ref Lab),3018298501,CDM,301,RC,82985,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fructosamine (Ref Lab),3018298501,CDM,301,RC,82985,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Fsh-Follicle Stimu Hormone,Ser (Ref Lab)",3018300101,CDM,301,RC,83001,HCPCS,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fsh-Follicle Stimu Hormone,Ser (Ref Lab)",3018300101,CDM,301,RC,83001,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Gonadotropin Follicle Stimulating Hormone,3018300102,CDM,301,RC,83001,HCPCS,,,facility,both,,,,211,158.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gonadotropin Follicle Stimulating Hormone,3018300102,CDM,301,RC,83001,HCPCS,,,facility,both,,,,211,158.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Luteinizing Hormone (Ref Lab),3018300201,CDM,301,RC,83002,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Luteinizing Hormone (Ref Lab),3018300201,CDM,301,RC,83002,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Gonadotropin Luteinizing Hormone,3018300202,CDM,301,RC,83002,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gonadotropin Luteinizing Hormone,3018300202,CDM,301,RC,83002,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Growth Hormone, Human (Ref Lab)",3018300301,CDM,301,RC,83003,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Growth Hormone, Human (Ref Lab)",3018300301,CDM,301,RC,83003,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Haptoglobin (Ref Lab),3018301001,CDM,301,RC,83010,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Haptoglobin (Ref Lab),3018301001,CDM,301,RC,83010,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Haptoglobin (Ref Lab),3018301001,CDM,301,RC,83010,HCPCS,,,facility,both,,,,18.98,14.24,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Assay Of Haptoglobin Quantitative,3018301002,CDM,301,RC,83010,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Assay Of Haptoglobin Quantitative,3018301002,CDM,301,RC,83010,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc H.Pylori Breath Test (Ref Lab),3018301301,CDM,301,RC,83013,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc H.Pylori Breath Test (Ref Lab),3018301301,CDM,301,RC,83013,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Molybdenum, Blood (Ref Lab)",3018301801,CDM,301,RC,83018,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Molybdenum, Blood (Ref Lab)",3018301801,CDM,301,RC,83018,HCPCS,,,facility,both,,,,185,138.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fftib-Tin, Blood",3018301802,CDM,301,RC,83018,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fftib-Tin, Blood",3018301802,CDM,301,RC,83018,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cos-Heavy Metal Quantiative Each Nes,3018301803,CDM,301,RC,83018,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cos-Heavy Metal Quantiative Each Nes,3018301803,CDM,301,RC,83018,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Tis-Heavy Metal Quantiative Each Nes,3018301804,CDM,301,RC,83018,HCPCS,,,facility,both,,,,204,153,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cowb-Heavy Metal Level,3018301805,CDM,301,RC,83018,HCPCS,,,facility,both,,,,377,282.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cowb-Heavy Metal Level,3018301805,CDM,301,RC,83018,HCPCS,,,facility,both,,,,377,282.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hemoglobin Electrophoresis, B (Ref Lab)",3018302001,CDM,301,RC,83020,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hemoglobin Electrophoresis, B (Ref Lab)",3018302001,CDM,301,RC,83020,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hemoglobin Electrophoresis, B (Ref Lab)",3018302002,CDM,301,RC,83020,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hbel1 Hemoglobin Electrophoresis,3018302003,CDM,301,RC,83020,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hbel1 Hemoglobin Electrophoresis,3018302003,CDM,301,RC,83020,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Hbel0-Hemoglobin Electrophoresis Evaluation, Blood",3018302004,CDM,301,RC,83020,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Hbel0-Hemoglobin Electrophoresis Evaluation, Blood",3018302004,CDM,301,RC,83020,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Hemoglobin Fractj/Quantj Electrophoresis,3018302005,CDM,301,RC,83020,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Hemoglobin Fractj/Quantj Electrophoresis,3018302005,CDM,301,RC,83020,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hemoglobin Variant,A2 + F Quantitation(Ref Lab)",3018302101,CDM,301,RC,83021,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hemoglobin Erythrocytosis (Ref Lab),3018302102,CDM,301,RC,83021,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hpcl Hb Variant, B (Ref Lab)",3018302103,CDM,301,RC,83021,HCPCS,,,facility,both,,,,350,262.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hbel1 Hemoglobin Chromotography,3018302104,CDM,301,RC,83021,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hbel1 Hemoglobin Chromotography,3018302104,CDM,301,RC,83021,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Hemoglobin Fractj/Quantj Chromotography,3018302106,CDM,301,RC,83021,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Hemoglobin Fractj/Quantj Chromotography,3018302106,CDM,301,RC,83021,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Mev1-Hemoglobin Analysis And Measurement, Chromatography",3018302107,CDM,301,RC,83021,HCPCS,,,facility,both,,,,96,72,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mev1-Hemoglobin Analysis And Measurement, Chromatography",3018302107,CDM,301,RC,83021,HCPCS,,,facility,both,,,,96,72,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Apt Test (Fetal Hgb),3018303301,CDM,301,RC,83033,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Apt Test (Fetal Hgb),3018303301,CDM,301,RC,83033,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Apt Test (Fetal Hgb),3018303301,CDM,301,RC,83033,HCPCS,,,facility,both,,,,8.8,6.6,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Glycohemoglobin,3018303601,CDM,301,RC,83036,HCPCS,,,facility,both,,,,104,78,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Glycohemoglobin,3018303601,CDM,301,RC,83036,HCPCS,,,facility,both,,,,73.53,55.15,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Glycohemoglobin,3018303601,CDM,301,RC,83036,HCPCS,,,facility,both,,,,8.98,6.74,,,,,,,,,,"Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Glycohemoglobin,3018303601,CDM,301,RC,83036,HCPCS,,,facility,both,,,,10.68,8.01,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Glycohemoglobin,3018303601,CDM,301,RC,83036,HCPCS,,,facility,both,,,,2.44,1.83,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Glycosylated Hemoglobin Tst Tc (Poc),3018303602,CDM,301,RC,83036,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Glycosylated Hemoglobin Tst Tc (Poc),3018303602,CDM,301,RC,83036,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Methemoglobin (Methb), Arterial",3018305001,CDM,301,RC,83050,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Methemoglobin (Methb), Arterial",3018305001,CDM,301,RC,83050,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Methemoglobin (Methb), Arterial",3018305001,CDM,301,RC,83050,HCPCS,,,facility,both,,,,9.02,6.76,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Methemoglobin (Methb), Capillary",3018305002,CDM,301,RC,83050,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Methemoglobin (Methb), Capillary",3018305002,CDM,301,RC,83050,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Methemoglobin (Methb), Capillary",3018305002,CDM,301,RC,83050,HCPCS,,,facility,both,,,,9.02,6.76,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Methemoglobin (Methb), Venous",3018305003,CDM,301,RC,83050,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Methemoglobin (Methb), Venous",3018305003,CDM,301,RC,83050,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Methemoglobin (Methb), Venous",3018305003,CDM,301,RC,83050,HCPCS,,,facility,both,,,,9.02,6.76,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Mayo Mev1-Hemoglobin Methemoglobin Quantitative,3018305004,CDM,301,RC,83050,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Mev1-Hemoglobin Methemoglobin Quantitative,3018305004,CDM,301,RC,83050,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hemoglobin, Plasma  (Ref Lab)",3018305101,CDM,301,RC,83051,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hemoglobin, Plasma  (Ref Lab)",3018305101,CDM,301,RC,83051,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Hemoglobin Unstable Screen,3018306801,CDM,301,RC,83068,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Hemoglobin Unstable Screen,3018306801,CDM,301,RC,83068,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Histamine Plasma (Ref Lab),3018308801,CDM,301,RC,83088,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Homocystine, Quant (Ref Lab)",3018309001,CDM,301,RC,83090,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Homocystine, Quant (Ref Lab)",3018309001,CDM,301,RC,83090,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Cmmps-Cobalamin,3018309002,CDM,301,RC,83090,HCPCS,,,facility,both,,,,263,197.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Cmmps-Cobalamin,3018309002,CDM,301,RC,83090,HCPCS,,,facility,both,,,,263,197.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Homocystine,3018309003,CDM,301,RC,83090,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Homocystine,3018309003,CDM,301,RC,83090,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Hva-Homovanillic Acid (Hva),3018315001,CDM,301,RC,83150,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Hva-Homovanillic Acid (Hva),3018315001,CDM,301,RC,83150,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Serotonin Metabolite, 5-Hiaa (Ref Lab)",3018349701,CDM,301,RC,83497,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Serotonin Metabolite, 5-Hiaa (Ref Lab)",3018349701,CDM,301,RC,83497,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc 5-Hiaa (5-Hydroxyindoleacetic) (Ref Lab),3018349702,CDM,301,RC,83497,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc 5-Hiaa (5-Hydroxyindoleacetic) (Ref Lab),3018349702,CDM,301,RC,83497,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc 17-Hydroxyprogesterone (Ref Lab),3018349801,CDM,301,RC,83498,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc 17-Hydroxyprogesterone (Ref Lab),3018349801,CDM,301,RC,83498,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anti-Gliadin Ab, Igg (Ref Lab)",3018351601,CDM,301,RC,83516,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Anti-Gliadin Ab, Igg (Ref Lab)",3018351601,CDM,301,RC,83516,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anti-Gliadin Ab, Iga (Ref Lab)",3018351602,CDM,301,RC,83516,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Anti-Gliadin Ab, Iga (Ref Lab)",3018351602,CDM,301,RC,83516,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Glomerular Basement Memb Ab (Ref Lab),3018351603,CDM,301,RC,83516,HCPCS,,,facility,both,,,,127,95.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Glomerular Basement Memb Ab (Ref Lab),3018351603,CDM,301,RC,83516,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mitochondrial M2 Antibody,Igg (Ref Lab)",3018351604,CDM,301,RC,83516,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mitochondrial M2 Antibody,Igg (Ref Lab)",3018351604,CDM,301,RC,83516,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ribosomal P Antibody (Ref Lab),3018351605,CDM,301,RC,83516,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ribosomal P Antibody (Ref Lab),3018351605,CDM,301,RC,83516,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tissue Transglutaminase Ab Iga (Ref Lab),3018351606,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tissue Transglutaminase Ab Iga (Ref Lab),3018351606,CDM,301,RC,83516,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tissue Transglutaminase Ab Igg (Ref Lab),3018351607,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tissue Transglutaminase Ab Igg (Ref Lab),3018351607,CDM,301,RC,83516,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Parietal Cell Ab, Igg, S (Ref Lab)",3018351608,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Parietal Cell Ab, Igg, S (Ref Lab)",3018351608,CDM,301,RC,83516,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Igg Monos. Gm1 (Ref Lab),3018351609,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igm Monos. Gm1 (Ref Lab),3018351610,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igg Asialo. Gm1 (Ref Lab),3018351611,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igm Asialo. Gm1 (Ref Lab),3018351612,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igg Disialo. Gd1B (Ref Lab),3018351613,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igm Disialo. Gd1B (Ref Lab),3018351614,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Pl-12 Ab (Ref Lab),3018351615,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Pl-7 Ab (Ref Lab),3018351616,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Ej Ab (Ref Lab),3018351617,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Oj Ab (Ref Lab),3018351618,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Srp Ab (Ref Lab),3018351619,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Ku Ab (Ref Lab),3018351620,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Asialo-Gm1 Antibodies, Igg-Igm (Ref Lab)",3018351621,CDM,301,RC,83516,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gm1 Antibodies, Igg-Igm (Ref Lab)",3018351622,CDM,301,RC,83516,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gm2 Antibodies, Igg-Igm (Ref Lab)",3018351623,CDM,301,RC,83516,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gd1A Antibodies, Igg-Igm (Ref Lab)",3018351624,CDM,301,RC,83516,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gd1B Antibodies, Igg-Igm (Ref Lab)",3018351625,CDM,301,RC,83516,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gq1B Antibodies, Igg-Igm (Ref Lab)",3018351626,CDM,301,RC,83516,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Centromere Ab, Igg (Ref Lab)",3018351627,CDM,301,RC,83516,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Centromere Ab, Igg (Ref Lab)",3018351627,CDM,301,RC,83516,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Auto Ab To Gmcsf (Ref Lab),3018351628,CDM,301,RC,83516,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Mda5 (P140)(Cadm-140) Ab (Ref Lab),3018351629,CDM,301,RC,83516,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Nxp2 (P140) Ab (Ref Lab),3018351630,CDM,301,RC,83516,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Tif1 Gamma (P155/140) Ab (Ref Lab),3018351631,CDM,301,RC,83516,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Myeloperoxidase Antibodies, Igg, Serum (Ref Lab)",3018351632,CDM,301,RC,83516,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Myeloperoxidase Antibodies, Igg, Serum (Ref Lab)",3018351632,CDM,301,RC,83516,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Myeloperoxidase Antibodies, Igg, Serum (Ref Lab)",3018351632,CDM,301,RC,83516,HCPCS,,,facility,both,,,,34.6,25.95,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Proteinase 3 Ab (Pr3), S (Ref Lab)",3018351633,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Proteinase 3 Antibodies, Igg, Serum (Ref Lab)",3018351634,CDM,301,RC,83516,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Proteinase 3 Antibodies, Igg, Serum (Ref Lab)",3018351634,CDM,301,RC,83516,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Proteinase 3 Antibodies, Igg, Serum (Ref Lab)",3018351634,CDM,301,RC,83516,HCPCS,,,facility,both,,,,35.22,26.42,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Myeloperoxidase Ab, S (Ref Lab)",3018351635,CDM,301,RC,83516,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dgldn Immunoassay Nonantibody,3018351636,CDM,301,RC,83516,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dgldn Immunoassay Nonantibody,3018351636,CDM,301,RC,83516,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dgldn Immunoassay Nonantibody,3018351637,CDM,301,RC,83516,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dgldn Immunoassay Nonantibody,3018351637,CDM,301,RC,83516,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351638,CDM,301,RC,83516,HCPCS,,,facility,both,,,,3.24,2.43,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351638,CDM,301,RC,83516,HCPCS,,,facility,both,,,,2.92,2.19,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351639,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351639,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351640,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351640,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351641,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351641,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351642,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351642,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351643,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Gm1B Immunoassay Nonantibody,3018351643,CDM,301,RC,83516,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Vasc Immunoassay Nonantibody,3018351644,CDM,301,RC,83516,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Vasc Immunoassay Nonantibody,3018351644,CDM,301,RC,83516,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Vasc Immunoassay Nonantibody,3018351645,CDM,301,RC,83516,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Vasc Immunoassay Nonantibody,3018351645,CDM,301,RC,83516,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rnap-Rna Polymerase Iii Antibodies, Igg, Serum",3018351647,CDM,301,RC,83516,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rnap-Rna Polymerase Iii Antibodies, Igg, Serum",3018351647,CDM,301,RC,83516,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Pl-7 Antibody,3018351648,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Pl-7 Antibody,3018351648,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Pl-12 Antibody,3018351649,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Pl-12 Antibody,3018351649,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Ej Antibody,3018351650,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Ej Antibody,3018351650,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Oj Antibody,3018351651,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Oj Antibody,3018351651,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Srp Antibody,3018351652,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Srp Antibody,3018351652,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Tif-1Gamma Antibody,3018351653,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Tif-1Gamma Antibody,3018351653,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Nxp-2 Antibody,3018351654,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Nxp-2 Antibody,3018351654,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Ku Antibody,3018351655,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Ku Antibody,3018351655,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp-Myomarker 3 Plus Profile,3018351656,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp-Myomarker 3 Plus Profile,3018351656,CDM,301,RC,83516,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  21Oh-21-Hydroxylase Ab, Serum",3018351657,CDM,301,RC,83516,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  21Oh-21-Hydroxylase Ab, Serum",3018351657,CDM,301,RC,83516,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Ffrft-Immunoassay Analyte Qual/Semiquan Multiple Step,3018351658,CDM,301,RC,83516,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Ffrft-Immunoassay Analyte Qual/Semiquan Multiple Step,3018351658,CDM,301,RC,83516,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Bpab-Bp 180 And 230, Serum",3018351660,CDM,301,RC,83516,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Bpab-Bp 180 And 230, Serum",3018351660,CDM,301,RC,83516,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fgagm-Ganglioside Antibodies, Igg-Igm",3018351661,CDM,301,RC,83516,HCPCS,,,facility,both,,,,672,504,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fgagm-Ganglioside Antibodies, Igg-Igm",3018351661,CDM,301,RC,83516,HCPCS,,,facility,both,,,,672,504,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fscpr-Scleroderma Comp Profile- Analysis Of Substance Using Immunoassay Technique, Multiple",3018351662,CDM,301,RC,83516,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fscpr-Scleroderma Comp Profile- Analysis Of Substance Using Immunoassay Technique, Multiple",3018351662,CDM,301,RC,83516,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw242-Collagen Type Vii Antibody Igg By Elisa,3018351663,CDM,301,RC,83516,HCPCS,,,facility,both,,,,176,132,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw242-Collagen Type Vii Antibody Igg By Elisa,3018351663,CDM,301,RC,83516,HCPCS,,,facility,both,,,,176,132,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Ffmi2-Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",3018351664,CDM,301,RC,83516,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Ffmi2-Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",3018351664,CDM,301,RC,83516,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup - Immunoassay For Analyte Other Than Infectious Agent Antibody Or Infectious Agent Antigen;,3018351665,CDM,301,RC,83516,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup - Immunoassay For Analyte Other Than Infectious Agent Antibody Or Infectious Agent Antigen;,3018351665,CDM,301,RC,83516,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Facn1-Immunoassay Analyte Qual/Semiquan Multiple Step,3018351666,CDM,301,RC,83516,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Facn1-Immunoassay Analyte Qual/Semiquan Multiple Step,3018351666,CDM,301,RC,83516,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fmnpp-Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",3018351667,CDM,301,RC,83516,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fmnpp-Analysis Of Substance Using Immunoassay Technique, Multiple Step Method",3018351667,CDM,301,RC,83516,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Aldef-Immunoassay Analyte Qual/Semiqual Single Step,3018351801,CDM,301,RC,83518,HCPCS,,,facility,both,,,,544,408,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aldef-Immunoassay Analyte Qual/Semiqual Single Step,3018351801,CDM,301,RC,83518,HCPCS,,,facility,both,,,,544,408,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Pinp-Procollagen I Intact N-Terminal, Serum",3018351902,CDM,301,RC,83519,HCPCS,,,facility,both,,,,244,183,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Pinp-Procollagen I Intact N-Terminal, Serum",3018351902,CDM,301,RC,83519,HCPCS,,,facility,both,,,,244,183,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fmgrp-Measurement Of Substance Using Immunoassay Technique, By Radioimmunoassay",3018351926,CDM,301,RC,83519,HCPCS,,,facility,both,,,,127,95.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fmgrp-Measurement Of Substance Using Immunoassay Technique, By Radioimmunoassay",3018351926,CDM,301,RC,83519,HCPCS,,,facility,both,,,,127,95.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw71-Immunoassay Analyte Quant Radioimmunoassay,3018351927,CDM,301,RC,83519,HCPCS,,,facility,both,,,,607,455.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw71-Immunoassay Analyte Quant Radioimmunoassay,3018351927,CDM,301,RC,83519,HCPCS,,,facility,both,,,,607,455.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Gid2-Immunoassay Analyte Quant Radioimmunoassay,3018351928,CDM,301,RC,83519,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Gid2-Immunoassay Analyte Quant Radioimmunoassay,3018351928,CDM,301,RC,83519,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kappa Free Light Chains (Ref Lab),3018352001,CDM,301,RC,83520,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lambda Free Light Chains (Ref Lab),3018352002,CDM,301,RC,83520,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Asca Iga Elisa (Outside Ref Lab),3018352005,CDM,301,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Asca Igg Elisa (Outside Ref Lab),3018352006,CDM,301,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Ompc Iga Elisa (Outside Ref Lab),3018352007,CDM,301,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Cbir1 Igg Elisa (Outside Ref Lab),3018352008,CDM,301,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-A4-Fla2 Igg Elisa (Outside Ref Lab),3018352009,CDM,301,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Flax Igg Elisa (Outside Ref Lab),3018352010,CDM,301,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dmoga Immunoassay Quant Nos Nonab,3018352011,CDM,301,RC,83520,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dmoga Immunoassay Quant Nos Nonab,3018352011,CDM,301,RC,83520,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dmoga Immunoassay Quant Nos Nonab,3018352012,CDM,301,RC,83520,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dmoga Immunoassay Quant Nos Nonab,3018352012,CDM,301,RC,83520,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pla2R Immunoassay Quant Nos Nonab,3018352013,CDM,301,RC,83520,HCPCS,,,facility,both,,,,265,198.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pla2R Immunoassay Quant Nos Nonab,3018352013,CDM,301,RC,83520,HCPCS,,,facility,both,,,,265,198.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Inhb-Inhibin B, Serum",3018352014,CDM,301,RC,83520,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Inhb-Inhibin B, Serum",3018352014,CDM,301,RC,83520,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fpf12-Prothrombin Fragment 1+2 Moab,3018352015,CDM,301,RC,83520,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fpf12-Prothrombin Fragment 1+2 Moab,3018352015,CDM,301,RC,83520,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fftac-Thrombin-Antithrombin Complex,3018352016,CDM,301,RC,83520,HCPCS,,,facility,both,,,,232,174,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fftac-Thrombin-Antithrombin Complex,3018352016,CDM,301,RC,83520,HCPCS,,,facility,both,,,,232,174,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Adevl-Alzheimer's Disease Evaluation, Spinal Fluid",3018352017,CDM,301,RC,83520,HCPCS,,,facility,both,,,,476,357,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Adevl-Alzheimer's Disease Evaluation, Spinal Fluid",3018352017,CDM,301,RC,83520,HCPCS,,,facility,both,,,,476,357,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Adlab-Adalimumab Antibody, Serum",3018352019,CDM,301,RC,83520,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Adlab-Adalimumab Antibody, Serum",3018352019,CDM,301,RC,83520,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Inhb-Inhibin B, Serum",3018352020,CDM,301,RC,83520,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Inhb-Inhibin B, Serum",3018352020,CDM,301,RC,83520,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Mda-5 Antibody,3018352021,CDM,301,RC,83520,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Mda-5 Antibody,3018352021,CDM,301,RC,83520,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Sae1 Ab, Igg",3018352022,CDM,301,RC,83520,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Sae1 Ab, Igg",3018352022,CDM,301,RC,83520,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp-Immunoassay For Analyte Other Than Infectious Agent Antibody Or Infectious Agent A,3018352023,CDM,301,RC,83520,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp-Immunoassay For Analyte Other Than Infectious Agent Antibody Or Infectious Agent A,3018352023,CDM,301,RC,83520,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Ustek-Immunoassay For Analyte Other Than Infectious Agent Antibody Or Infectious Agent A,3018352024,CDM,301,RC,83520,HCPCS,,,facility,both,,,,163,122.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Ustek-Immunoassay For Analyte Other Than Infectious Agent Antibody Or Infectious Agent A,3018352024,CDM,301,RC,83520,HCPCS,,,facility,both,,,,163,122.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phospholipase A2 Receptor Antibodies, Serum (Ref Lab)",3018352036,CDM,301,RC,83520,HCPCS,,,facility,both,,,,224,168,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Adlab-Adalimumab Antibody, Serum",3018352037,CDM,301,RC,83520,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Adlab-Adalimumab Antibody, Serum",3018352037,CDM,301,RC,83520,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Pmnd1-Primary Membranous Nephropathy Diagnostic Cascade, Serum",3018352038,CDM,301,RC,83520,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Pmnd1-Primary Membranous Nephropathy Diagnostic Cascade, Serum",3018352038,CDM,301,RC,83520,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Igats-Igg Asialo Gm1 Titer, Serum",3018352040,CDM,301,RC,83520,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Igats-Igg Asialo Gm1 Titer, Serum",3018352040,CDM,301,RC,83520,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Vegf-Measurement Of Substance Using Immunoassay Technique,3018352041,CDM,301,RC,83520,HCPCS,,,facility,both,,,,229,171.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Vegf-Measurement Of Substance Using Immunoassay Technique,3018352041,CDM,301,RC,83520,HCPCS,,,facility,both,,,,229,171.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Famda-Immunoassay Analyte Quantitative Nos,3018352042,CDM,301,RC,83520,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Famda-Immunoassay Analyte Quantitative Nos,3018352042,CDM,301,RC,83520,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fgq1B-Ganglioside,3018352043,CDM,301,RC,83520,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fgq1B-Ganglioside,3018352043,CDM,301,RC,83520,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fhtgf-Human Transforming Growth Factor B1,3018352044,CDM,301,RC,83520,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fhtgf-Human Transforming Growth Factor B1,3018352044,CDM,301,RC,83520,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Pla2M-Pla2R, Monitoring, Elisa, Serum",3018352045,CDM,301,RC,83520,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Pla2M-Pla2R, Monitoring, Elisa, Serum",3018352045,CDM,301,RC,83520,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Igmts-Igg Monos Gm1 Titer, Serum",3018352046,CDM,301,RC,83520,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Igmts-Igg Monos Gm1 Titer, Serum",3018352046,CDM,301,RC,83520,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Igdts-Igg Disialo Gd1B Titer, Serum",3018352047,CDM,301,RC,83520,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Igdts-Igg Disialo Gd1B Titer, Serum",3018352047,CDM,301,RC,83520,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Igats-Igg Asialo Gm1 Titer, Serum",3018352048,CDM,301,RC,83520,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Igats-Igg Asialo Gm1 Titer, Serum",3018352048,CDM,301,RC,83520,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw57-Mmp-9 (Matrix Metalloproteinase-9),3018352049,CDM,301,RC,83520,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw57-Mmp-9 (Matrix Metalloproteinase-9),3018352049,CDM,301,RC,83520,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cyt13 Csf-Arup: Measurement Of Substance Using Immunoassay Technique,3018352050,CDM,301,RC,83520,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyt13 Csf-Arup: Measurement Of Substance Using Immunoassay Technique,3018352050,CDM,301,RC,83520,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw143 - Immunoassay For Analyte Other Than Infectious Agent Antibody Or Infectious Agent Ant,3018352051,CDM,301,RC,83520,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw143 - Immunoassay For Analyte Other Than Infectious Agent Antibody Or Infectious Agent Ant,3018352051,CDM,301,RC,83520,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cjde-Immunoassay For Analyte Other Than Infectious Agent Antibody Or Infectious Agent Antige,3018352052,CDM,301,RC,83520,HCPCS,,,facility,both,,,,590,442.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fcxcl-Immunoassay Analyte Quantitative Nos,3018352053,CDM,301,RC,83520,HCPCS,,,facility,both,,,,495,371.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw239-Immunoassay Analyte Quantitative Nos,3018352054,CDM,301,RC,83520,HCPCS,,,facility,both,,,,514,385.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fslaa-Immunoassay Analyte Quantitative Nos,3018352055,CDM,301,RC,83520,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fslaa-Immunoassay Analyte Quantitative Nos,3018352055,CDM,301,RC,83520,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Immunoglbulin Light Chains (Ie,Kappa,Lambda)Free Each",3018352101,CDM,301,RC,83521,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Flcs-Immunoglobulin Free Light Chains, Serum",3018352102,CDM,301,RC,83521,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Flcs-Immunoglobulin Free Light Chains, Serum",3018352102,CDM,301,RC,83521,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Msp3-Ms Profile, Serum And Spinal Fluid",3018352103,CDM,301,RC,83521,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Msp3-Ms Profile, Serum And Spinal Fluid",3018352103,CDM,301,RC,83521,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Dmoga-Immunoglobulin Light Chains (Ie, Kappa, Lambda), Free, Each",3018352104,CDM,301,RC,83521,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Dmoga-Immunoglobulin Light Chains (Ie, Kappa, Lambda), Free, Each",3018352104,CDM,301,RC,83521,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Kcsf-Measurement Of Immunoglobulin Light Chains,3018352105,CDM,301,RC,83521,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Kcsf-Measurement Of Immunoglobulin Light Chains,3018352105,CDM,301,RC,83521,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insulin Assay (Ref Lab),3018352501,CDM,301,RC,83525,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insulin Assay (Ref Lab),3018352501,CDM,301,RC,83525,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Insulin, Total (Ref Lab)",3018352502,CDM,301,RC,83525,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Insulin, Total (Ref Lab)",3018352502,CDM,301,RC,83525,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Insft Assay Of Insulin,3018352503,CDM,301,RC,83525,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Insulin, Free (Ref Lab)",3018352701,CDM,301,RC,83527,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Insulin, Free (Ref Lab)",3018352701,CDM,301,RC,83527,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Insft Assay Of Insulin,3018352702,CDM,301,RC,83527,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Il6Dx-Interleukin-6, Serum",3018352902,CDM,301,RC,83529,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Il6Dx-Interleukin-6, Serum",3018352902,CDM,301,RC,83529,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fcytp-Cytokine Panel 13,3018352903,CDM,301,RC,83529,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fcytp-Cytokine Panel 13,3018352903,CDM,301,RC,83529,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup - Assay Of Interleukin-6 (Il-6),3018352905,CDM,301,RC,83529,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup - Assay Of Interleukin-6 (Il-6),3018352905,CDM,301,RC,83529,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Iron,3018354001,CDM,301,RC,83540,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iron,3018354001,CDM,301,RC,83540,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Iron,3018354001,CDM,301,RC,83540,HCPCS,,,facility,both,,,,7.13,5.35,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Iron,3018354001,CDM,301,RC,83540,HCPCS,,,facility,both,,,,7.12,5.34,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Iron,3018354001,CDM,301,RC,83540,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Iron Binding Capacity,3018355001,CDM,301,RC,83550,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iron Binding Capacity,3018355001,CDM,301,RC,83550,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Iron Binding Capacity,3018355001,CDM,301,RC,83550,HCPCS,,,facility,both,,,,7.13,5.35,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Iron Binding Capacity,3018355001,CDM,301,RC,83550,HCPCS,,,facility,both,,,,11.94,8.96,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Iron Binding Capacity,3018355001,CDM,301,RC,83550,HCPCS,,,facility,both,,,,2.13,1.6,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Lactate/Lactic Acid,3018360501,CDM,301,RC,83605,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lactate/Lactic Acid,3018360501,CDM,301,RC,83605,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lactate/Lactic Acid,3018360501,CDM,301,RC,83605,HCPCS,,,facility,both,,,,12.73,9.55,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Lactate/Lactic Acid,3018360501,CDM,301,RC,83605,HCPCS,,,facility,both,,,,4.49,3.37,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Lactate/Lactic Acid Poc,3018360502,CDM,301,RC,83605,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ldh,3018361501,CDM,301,RC,83615,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ldh,3018361501,CDM,301,RC,83615,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ldh,3018361501,CDM,301,RC,83615,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Ldh,3018361501,CDM,301,RC,83615,HCPCS,,,facility,both,,,,6.64,4.98,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Ldh,3018361501,CDM,301,RC,83615,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Lactate Dehydrogenase (Ld) (Ref Lab),3018361502,CDM,301,RC,83615,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lactate Dehydrogenase (Ld) (Ref Lab),3018361502,CDM,301,RC,83615,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Lactate Dehydrogenase, Csf (Ref Lab)",3018361503,CDM,301,RC,83615,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ld_I Lactate (Ld) (Ldh) Enzyme,3018361504,CDM,301,RC,83615,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ld_I Lactate (Ld) (Ldh) Enzyme,3018361504,CDM,301,RC,83615,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ld Isoenzymes (Ref Lab),3018362501,CDM,301,RC,83625,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ld_I Assay Of Ldh Enzymes,3018362502,CDM,301,RC,83625,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ld_I Assay Of Ldh Enzymes,3018362502,CDM,301,RC,83625,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Lactoferrin,Fecal,Qual",3018363001,CDM,301,RC,83630,HCPCS,,,facility,both,,,,145,108.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lactoferrin,Fecal,Qual",3018363001,CDM,301,RC,83630,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Lactoferrin,Fecal,Qual",3018363001,CDM,301,RC,83630,HCPCS,,,facility,both,,,,21.67,16.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Lactoferrin, Fecal By Elisa (Ref Lab)",3018363002,CDM,301,RC,83630,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lactoferrin, Fecal By Elisa (Ref Lab)",3018363002,CDM,301,RC,83630,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lead Level (Ref Lab),3018365501,CDM,301,RC,83655,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lead Level (Ref Lab),3018365501,CDM,301,RC,83655,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lead (Ref Lab),3018365502,CDM,301,RC,83655,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lead Testing, Poc",3018365503,CDM,301,RC,83655,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lead Testing, Poc",3018365503,CDM,301,RC,83655,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Kh  Mayo Hmdb Assay Of Lead,3018365504,CDM,301,RC,83655,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hmdb Assay Of Lead,3018365504,CDM,301,RC,83655,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hmu24-Assay Of Lead,3018365506,CDM,301,RC,83655,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Hmu24-Assay Of Lead,3018365506,CDM,301,RC,83655,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lipase,3018369001,CDM,301,RC,83690,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lipase,3018369001,CDM,301,RC,83690,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lipase,3018369001,CDM,301,RC,83690,HCPCS,,,facility,both,,,,10.4,7.8,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Lipase,3018369001,CDM,301,RC,83690,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Kh Mayo Lpsbf-Lipase, Body Fluid",3018369002,CDM,301,RC,83690,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Lpsbf-Lipase, Body Fluid",3018369002,CDM,301,RC,83690,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lipoprotein A (Ref Lab),3018369501,CDM,301,RC,83695,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lipoprotein A (Ref Lab),3018369501,CDM,301,RC,83695,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Crmp1-Lipoprotein (A),3018369502,CDM,301,RC,83695,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw131-Lipoprotein-Associated Phospholipase A2 (Enzyme) Level,3018369801,CDM,301,RC,83698,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw131-Lipoprotein-Associated Phospholipase A2 (Enzyme) Level,3018369801,CDM,301,RC,83698,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Lmpp-Lipoprotein Metabolism Profile 1,3018370001,CDM,301,RC,83700,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Lmpp-Lipoprotein Metabolism Profile 1,3018370001,CDM,301,RC,83700,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Lpald-Low-Density Lipoprotein Cholesterol, Serum",3018370002,CDM,301,RC,83700,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Lpald-Low-Density Lipoprotein Cholesterol, Serum",3018370002,CDM,301,RC,83700,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Lpald-Lipoprotein (A),3018370101,CDM,301,RC,83701,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Lpald-Lipoprotein (A),3018370101,CDM,301,RC,83701,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Nmr Lipoprotein Profile (Ref Lab),3018370401,CDM,301,RC,83704,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nmr Lipoprotein Profile (Ref Lab),3018370401,CDM,301,RC,83704,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Nmrlp-Nuclear Magnetic Resonance Lipoprotein Profile, Serum",3018370402,CDM,301,RC,83704,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Nmrlp-Nuclear Magnetic Resonance Lipoprotein Profile, Serum",3018370402,CDM,301,RC,83704,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hdl Cholesterol,3018371801,CDM,301,RC,83718,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hdl Cholesterol,3018371801,CDM,301,RC,83718,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hdl Cholesterol,3018371801,CDM,301,RC,83718,HCPCS,,,facility,both,,,,9.01,6.76,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Kh Mayo  Lmpp-Hdl Cholesterol, Cdc, S",3018371802,CDM,301,RC,83718,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Lmpp-Hdl Cholesterol, Cdc, S",3018371802,CDM,301,RC,83718,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Crmp1-Lipoprotein, Direct Measurement; High Density Cholesterol (Hdl Cholesterol)",3018371803,CDM,301,RC,83718,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ldl Cholesterol, Direct (Ref Lab)",3018372101,CDM,301,RC,83721,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ldl Cholesterol, Direct (Ref Lab)",3018372101,CDM,301,RC,83721,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Sdldl-Lipoprotein, Direct Measurement; Small Dense Ldl Cholesterol",3018372201,CDM,301,RC,83722,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Sdldl-Lipoprotein, Direct Measurement; Small Dense Ldl Cholesterol",3018372201,CDM,301,RC,83722,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Magnesium, Serum",3018373501,CDM,301,RC,83735,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Magnesium, Serum",3018373501,CDM,301,RC,83735,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Magnesium, Serum",3018373501,CDM,301,RC,83735,HCPCS,,,facility,both,,,,7.37,5.53,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Magnesium, Serum",3018373501,CDM,301,RC,83735,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Neonate Chem Mag,3018373502,CDM,301,RC,83735,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Chem Mag,3018373502,CDM,301,RC,83735,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Magnesium, Urine (Ref Lab)",3018373503,CDM,301,RC,83735,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Magnesium, Urine (Ref Lab)",3018373503,CDM,301,RC,83735,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Magnesium, F (Ref Lab)",3018373504,CDM,301,RC,83735,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Magnesium, F (Ref Lab)",3018373504,CDM,301,RC,83735,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Efpo Assay Of Magnesium,3018373505,CDM,301,RC,83735,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Efpo Assay Of Magnesium,3018373505,CDM,301,RC,83735,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Magnesium,3018373506,CDM,301,RC,83735,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Magnesium,3018373506,CDM,301,RC,83735,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Manganese (Ref Lab),3018378501,CDM,301,RC,83785,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Manganese (Ref Lab),3018378501,CDM,301,RC,83785,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mns - Assay Of Manganese,3018378502,CDM,301,RC,83785,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Mns - Assay Of Manganese,3018378502,CDM,301,RC,83785,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Iodine, Serum (Ref Lab)",3018378901,CDM,301,RC,83789,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Iodine, Serum (Ref Lab)",3018378901,CDM,301,RC,83789,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hb Variant Mass Spec, B (Ref Lab)",3018378902,CDM,301,RC,83789,HCPCS,,,facility,both,,,,468,351,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hb Variant By Mass Spec, B (Ref Lab)",3018378903,CDM,301,RC,83789,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Mass-Hemoglobin Variant By Mass Spec,3018378904,CDM,301,RC,83789,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Mass-Hemoglobin Variant By Mass Spec,3018378904,CDM,301,RC,83789,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Mass-Hemoglobin Variant By Mass Spec,3018378905,CDM,301,RC,83789,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Mass-Hemoglobin Variant By Mass Spec,3018378905,CDM,301,RC,83789,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Uiod-Iodine, 24 Hour Urine",3018378906,CDM,301,RC,83789,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Uiod-Iodine, 24 Hour Urine",3018378906,CDM,301,RC,83789,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Reve2-Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea,3018378908,CDM,301,RC,83789,HCPCS,,,facility,both,,,,468,351,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Reve2-Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea,3018378908,CDM,301,RC,83789,HCPCS,,,facility,both,,,,468,351,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mercury (Ref Lab),3018382501,CDM,301,RC,83825,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mercury (Ref Lab),3018382501,CDM,301,RC,83825,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Hmdb Assay Of Mercury,3018382502,CDM,301,RC,83825,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hmdb Assay Of Mercury,3018382502,CDM,301,RC,83825,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hmu24-Assay Of Mercury Quantitative,3018382504,CDM,301,RC,83825,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Hmu24-Assay Of Mercury Quantitative,3018382504,CDM,301,RC,83825,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Metanepharines, Fract, Urine (Ref Lab)",3018383501,CDM,301,RC,83835,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Metanepharines, Fract, Urine (Ref Lab)",3018383501,CDM,301,RC,83835,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Metanephrines, Fract, Free Plasma (Ref Lab)",3018383502,CDM,301,RC,83835,HCPCS,,,facility,both,,,,154,115.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Metanephrines, Fract, Free Plasma (Ref Lab)",3018383502,CDM,301,RC,83835,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Meta3-Metanephrines Level,3018383503,CDM,301,RC,83835,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Meta3-Metanephrines Level,3018383503,CDM,301,RC,83835,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Myoglobin,3018387401,CDM,301,RC,83874,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Myoglobin,3018387401,CDM,301,RC,83874,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Myoglobin,3018387401,CDM,301,RC,83874,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Myoglobin,3018387401,CDM,301,RC,83874,HCPCS,,,facility,both,,,,14.21,10.66,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Myoglobin,3018387401,CDM,301,RC,83874,HCPCS,,,facility,both,,,,2.55,1.91,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc B-Type Natriuretic Peptide,3018388001,CDM,301,RC,83880,HCPCS,,,facility,both,,,,307,230.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-Type Natriuretic Peptide,3018388001,CDM,301,RC,83880,HCPCS,,,facility,both,,,,206.54,154.9,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc B-Type Natriuretic Peptide,3018388001,CDM,301,RC,83880,HCPCS,,,facility,both,,,,69.72,52.29,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc B-Type Natriuretic Peptide,3018388001,CDM,301,RC,83880,HCPCS,,,facility,both,,,,46.8,35.1,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc B-Type Natriuretic Peptide,3018388001,CDM,301,RC,83880,HCPCS,,,facility,both,,,,18.21,13.66,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Free Urinary Kappa Light Chain (Ref Lab),3018388303,CDM,301,RC,83883,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Free Urinary Kappa Light Chain (Ref Lab),3018388303,CDM,301,RC,83883,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Free Urinary Lambda Light Chns (Ref Lab),3018388304,CDM,301,RC,83883,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Free Urinary Lambda Light Chns (Ref Lab),3018388304,CDM,301,RC,83883,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C1 Esterase Inhibitor Antigen (Ref Lab),3018388305,CDM,301,RC,83883,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C1 Esterase Inhibitor Antigen (Ref Lab),3018388305,CDM,301,RC,83883,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Retinol Binding Protein (Ref Lab),3018388306,CDM,301,RC,83883,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Retinol Binding Protein (Ref Lab),3018388306,CDM,301,RC,83883,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kappa Free Lt Chain, S (Ref Lab)",3018388307,CDM,301,RC,83883,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kappa Free Lt Chain, S (Ref Lab)",3018388307,CDM,301,RC,83883,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Flcp Assay Nephelometry Not Spec,3018388309,CDM,301,RC,83883,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Flcp Assay Nephelometry Not Spec,3018388309,CDM,301,RC,83883,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Flcp Assay Nephelometry Not Spec,3018388310,CDM,301,RC,83883,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Flcp Assay Nephelometry Not Spec,3018388310,CDM,301,RC,83883,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Zw83-Aspergillus Dna, Pcr To Quest",3018388312,CDM,301,RC,83883,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Zw83-Aspergillus Dna, Pcr To Quest",3018388312,CDM,301,RC,83883,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Btpbf-Nephelometry, Test Method Using Light",3018388313,CDM,301,RC,83883,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fhlcg-Igg Heavy Light Chains (Hlc), Serum",3018388314,CDM,301,RC,83883,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fhlca-Iga Heavy Light Chains (Hlc), Serum",3018388315,CDM,301,RC,83883,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fhlc-Igm Heavy Light Chains (Hlc), S",3018388316,CDM,301,RC,83883,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc F5Nul - 5'Nucleotidase (Ref Lab),3018391501,CDM,301,RC,83915,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc F5Nul - 5'Nucleotidase (Ref Lab),3018391501,CDM,301,RC,83915,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Assay Of Nucleotidase 5'-,3018391502,CDM,301,RC,83915,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Assay Of Nucleotidase 5'-,3018391502,CDM,301,RC,83915,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo P5Nt-Assay Of Nucleotidase 5'-,3018391504,CDM,301,RC,83915,HCPCS,,,facility,both,,,,196,147,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo P5Nt-Assay Of Nucleotidase 5'-,3018391504,CDM,301,RC,83915,HCPCS,,,facility,both,,,,196,147,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Oligoclonal Band, Serum (Ref Lab)",3018391601,CDM,301,RC,83916,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Oligoclonal Band, Csf (Ref Lab)",3018391602,CDM,301,RC,83916,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Oligoclonal Banding, Serum (Ref Lab)",3018391603,CDM,301,RC,83916,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Oligoclonal Banding, Serum (Ref Lab)",3018391603,CDM,301,RC,83916,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Oligoclonal Banding, Spinal Fl (Ref Lab)",3018391604,CDM,301,RC,83916,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Oligoclonal Banding, Spinal Fl (Ref Lab)",3018391604,CDM,301,RC,83916,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Olig Oligoclonal Bands,3018391605,CDM,301,RC,83916,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Olig Oligoclonal Bands,3018391605,CDM,301,RC,83916,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Olig Oligoclonal Bands,3018391606,CDM,301,RC,83916,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Olig Oligoclonal Bands,3018391606,CDM,301,RC,83916,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Cmmps-Methionine,3018391801,CDM,301,RC,83918,HCPCS,,,facility,both,,,,545,408.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Cmmps-Methionine,3018391801,CDM,301,RC,83918,HCPCS,,,facility,both,,,,345,258.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Organic Acid Screen, Urine (Ref Lab)",3018391901,CDM,301,RC,83919,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Organic Acid Screen, Urine (Ref Lab)",3018391901,CDM,301,RC,83919,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Methylmalonic Acid,Quant Mayo (Ref Lab)",3018392101,CDM,301,RC,83921,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Methylmalonic Acid,Quant Mayo (Ref Lab)",3018392101,CDM,301,RC,83921,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Methylmalonic Acid, Qn, S (Ref Lab)",3018392102,CDM,301,RC,83921,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Methylmalonic Acid, Qn, S (Ref Lab)",3018392102,CDM,301,RC,83921,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Osmolality, Blood",3018393001,CDM,301,RC,83930,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Osmolality, Blood",3018393001,CDM,301,RC,83930,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Osmolality, Blood",3018393001,CDM,301,RC,83930,HCPCS,,,facility,both,,,,14.29,10.72,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Osmolality, Blood",3018393001,CDM,301,RC,83930,HCPCS,,,facility,both,,,,9.58,7.18,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Osmolality, Urine",3018393501,CDM,301,RC,83935,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Osmolality, Urine",3018393501,CDM,301,RC,83935,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Osmolality, Urine",3018393501,CDM,301,RC,83935,HCPCS,,,facility,both,,,,12.29,9.22,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Osmolality, Urine",3018393501,CDM,301,RC,83935,HCPCS,,,facility,both,,,,9.58,7.18,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Osmolality, Urine, 24 Hour  (Ref Lab)",3018393502,CDM,301,RC,83935,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Osmolality, Urine, 24 Hour  (Ref Lab)",3018393502,CDM,301,RC,83935,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Osmolality,3018393503,CDM,301,RC,83935,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Osmolality,3018393503,CDM,301,RC,83935,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Oscal-Osteocalcin, Serum",3018393701,CDM,301,RC,83937,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Oscal-Osteocalcin, Serum",3018393701,CDM,301,RC,83937,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Oxalate, Urine, 24 Hour (Ref Lab)",3018394501,CDM,301,RC,83945,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Oxalate, Urine, 24 Hour (Ref Lab)",3018394501,CDM,301,RC,83945,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Oxalate,3018394502,CDM,301,RC,83945,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Oxalate,3018394502,CDM,301,RC,83945,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Poxa1-Oxalate, Plasma",3018394503,CDM,301,RC,83945,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Poxa1-Oxalate, Plasma",3018394503,CDM,301,RC,83945,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Parathyroid Hormone, Intact",3018397001,CDM,301,RC,83970,HCPCS,,,facility,both,,,,370,277.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Parathyroid Hormone, Intact",3018397001,CDM,301,RC,83970,HCPCS,,,facility,both,,,,180.59,135.44,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Parathyroid Hormone, Intact",3018397001,CDM,301,RC,83970,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Parathyroid Hormone, Intact",3018397001,CDM,301,RC,83970,HCPCS,,,facility,both,,,,45.41,34.06,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Parathyroid Hormone (Pth) (Ref Lab),3018397002,CDM,301,RC,83970,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Parathyroid Hormone (Pth) (Ref Lab),3018397002,CDM,301,RC,83970,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ph, Body Fluid",3018398601,CDM,301,RC,83986,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ph, Body Fluid",3018398601,CDM,301,RC,83986,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ph, Body Fluid",3018398601,CDM,301,RC,83986,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Ph, Urine, 24 Hour (Ref Lab)",3018398602,CDM,301,RC,83986,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ph, Urine, 24 Hour (Ref Lab)",3018398602,CDM,301,RC,83986,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ph, Random, Urine (Ref Lab)",3018398603,CDM,301,RC,83986,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ph, Random, Urine (Ref Lab)",3018398603,CDM,301,RC,83986,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Ph Body Fluid Nos,3018398604,CDM,301,RC,83986,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Ph Body Fluid Nos,3018398604,CDM,301,RC,83986,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phencyclidine Confirm, Coc, U (Ref Lab)",3018399201,CDM,301,RC,83992,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phencyclidine Confirm, Coc, U (Ref Lab)",3018399201,CDM,301,RC,83992,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drugscan: Assay Of Phencyclidine,3018399202,CDM,301,RC,83992,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drugscan: Assay Of Phencyclidine,3018399202,CDM,301,RC,83992,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Calprotectin, Fecal (Ref Lab)",3018399301,CDM,301,RC,83993,HCPCS,,,facility,both,,,,371,278.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calprotectin, Fecal (Ref Lab)",3018399301,CDM,301,RC,83993,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Calprotectin, Fecal (Ref Lab)",3018399301,CDM,301,RC,83993,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Alkaline Phosphatase,3018407501,CDM,301,RC,84075,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Alkaline Phosphatase,3018407501,CDM,301,RC,84075,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Alkaline Phosphatase,3018407501,CDM,301,RC,84075,HCPCS,,,facility,both,,,,5.7,4.28,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Alkaline Phosphatase,3018407501,CDM,301,RC,84075,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Neonate Chem Alk Phos,3018407502,CDM,301,RC,84075,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Chem Alk Phos,3018407502,CDM,301,RC,84075,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Alkaline Phosphatase, S (Ref Lab)",3018407503,CDM,301,RC,84075,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Alki Assay Alkaline Phosphatase,3018407504,CDM,301,RC,84075,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Alki Assay Alkaline Phosphatase,3018407504,CDM,301,RC,84075,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Alkaline Phosphatase Isoenzyme (Ref Lab),3018408001,CDM,301,RC,84080,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Alkaline Phosphatase Isoenzyme (Ref Lab),3018408001,CDM,301,RC,84080,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Alki Assay Alkaline Phosphatases,3018408002,CDM,301,RC,84080,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Alki Assay Alkaline Phosphatases,3018408002,CDM,301,RC,84080,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Assay Of Phosphohexose Isomerase,3018408701,CDM,301,RC,84087,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Assay Of Phosphohexose Isomerase,3018408701,CDM,301,RC,84087,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phosphorus,3018410001,CDM,301,RC,84100,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phosphorus,3018410001,CDM,301,RC,84100,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Phosphorus,3018410001,CDM,301,RC,84100,HCPCS,,,facility,both,,,,5.21,3.91,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Phosphorus,3018410001,CDM,301,RC,84100,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Neonate Chem Phos,3018410002,CDM,301,RC,84100,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Chem Phos,3018410002,CDM,301,RC,84100,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phosphorus, F",3018410003,CDM,301,RC,84100,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phosphorus, F",3018410003,CDM,301,RC,84100,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Efpo Assay Of Phosphorus,3018410004,CDM,301,RC,84100,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Efpo Assay Of Phosphorus,3018410004,CDM,301,RC,84100,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phosphorus, 24 Hour, Urine (Ref Lab)",3018410501,CDM,301,RC,84105,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phosphorus, 24 Hour, Urine (Ref Lab)",3018410501,CDM,301,RC,84105,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Phosphorus,3018410502,CDM,301,RC,84105,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Phosphorus,3018410502,CDM,301,RC,84105,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Porphobilinogen, Quantitative (Ref Lab)",3018411001,CDM,301,RC,84110,HCPCS,,,facility,both,,,,103,77.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Porphobilinogen, Quantitative (Ref Lab)",3018411001,CDM,301,RC,84110,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pqnru Assay Of Porphobilinogen,3018411002,CDM,301,RC,84110,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pqnru Assay Of Porphobilinogen,3018411002,CDM,301,RC,84110,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pqnu Assay Of Porphobilinogen,3018411003,CDM,301,RC,84110,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pqnu Assay Of Porphobilinogen,3018411003,CDM,301,RC,84110,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rupture Of Membranes (Rom+),3018411201,CDM,301,RC,84112,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rupture Of Membranes (Rom+),3018411201,CDM,301,RC,84112,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rupture Of Membranes (Rom+),3018411201,CDM,301,RC,84112,HCPCS,,,facility,both,,,,107.92,80.94,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Porphyrins, Quantitative, 24 Hour, Urine (Ref Lab)",3018412001,CDM,301,RC,84120,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Porphyrins, Quantitative, Random, Urine (Ref Lab)",3018412002,CDM,301,RC,84120,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Porphyrins, Quantitative, Random, Urine (Ref Lab)",3018412002,CDM,301,RC,84120,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pqnru Assay Of Urine Porphyrins,3018412003,CDM,301,RC,84120,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pqnru Assay Of Urine Porphyrins,3018412003,CDM,301,RC,84120,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pqnu Assay Of Urine Porphyrins,3018412004,CDM,301,RC,84120,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pqnu Assay Of Urine Porphyrins,3018412004,CDM,301,RC,84120,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Potassium, Serum",3018413201,CDM,301,RC,84132,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Potassium, Serum",3018413201,CDM,301,RC,84132,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Potassium, Serum",3018413201,CDM,301,RC,84132,HCPCS,,,facility,both,,,,5.24,3.93,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Potassium, Serum",3018413201,CDM,301,RC,84132,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Potassium, Poc",3018413202,CDM,301,RC,84132,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Potassium, Urine",3018413301,CDM,301,RC,84133,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Potassium, Urine",3018413301,CDM,301,RC,84133,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Potassium, Urine",3018413301,CDM,301,RC,84133,HCPCS,,,facility,both,,,,28.28,21.21,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Potassium, Urine",3018413301,CDM,301,RC,84133,HCPCS,,,facility,both,,,,5.24,3.93,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Potassium, Urine, 24 Hour  (Ref Lab)",3018413302,CDM,301,RC,84133,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Potassium, Urine, 24 Hour  (Ref Lab)",3018413302,CDM,301,RC,84133,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Potassium,3018413303,CDM,301,RC,84133,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Potassium,3018413303,CDM,301,RC,84133,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pre-Albumin (Ref Lab),3018413401,CDM,301,RC,84134,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pre-Albumin (Ref Lab),3018413401,CDM,301,RC,84134,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Prealbumin,3018413402,CDM,301,RC,84134,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prealbumin,3018413402,CDM,301,RC,84134,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Prealbumin,3018413402,CDM,301,RC,84134,HCPCS,,,facility,both,,,,15.55,11.66,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Prealbumin,3018413402,CDM,301,RC,84134,HCPCS,,,facility,both,,,,16.05,12.04,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Prealbumin,3018413402,CDM,301,RC,84134,HCPCS,,,facility,both,,,,3.89,2.92,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Pregnenolone,3018414001,CDM,301,RC,84140,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pregnenolone,3018414001,CDM,301,RC,84140,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pregnenolone (Ref Lab),3018414002,CDM,301,RC,84140,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pregnenolone (Ref Lab),3018414002,CDM,301,RC,84140,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc 17-Hydroxypregnenolone (Ref Lab),3018414301,CDM,301,RC,84143,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc 17-Hydroxypregnenolone (Ref Lab),3018414301,CDM,301,RC,84143,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Progesterone (Ref Lab),3018414401,CDM,301,RC,84144,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Progesterone (Ref Lab),3018414401,CDM,301,RC,84144,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Assay Of Progesterone,3018414402,CDM,301,RC,84144,HCPCS,,,facility,both,,,,103,77.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Assay Of Progesterone,3018414402,CDM,301,RC,84144,HCPCS,,,facility,both,,,,103,77.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw71-Assay Of Progesterone,3018414403,CDM,301,RC,84144,HCPCS,,,facility,both,,,,140,105,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw71-Assay Of Progesterone,3018414403,CDM,301,RC,84144,HCPCS,,,facility,both,,,,140,105,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Procalcitonin,3018414501,CDM,301,RC,84145,HCPCS,,,facility,both,,,,302,226.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Procalcitonin,3018414501,CDM,301,RC,84145,HCPCS,,,facility,both,,,,261,195.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Procalcitonin,3018414501,CDM,301,RC,84145,HCPCS,,,facility,both,,,,105.3,78.98,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Procalcitonin,3018414501,CDM,301,RC,84145,HCPCS,,,facility,both,,,,40.43,30.32,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Prolactin (Ref Lab),3018414601,CDM,301,RC,84146,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prolactin (Ref Lab),3018414601,CDM,301,RC,84146,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Assay Of Prolactin,3018414602,CDM,301,RC,84146,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Assay Of Prolactin,3018414602,CDM,301,RC,84146,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mcrpl-Macroprolactin, Serum",3018414603,CDM,301,RC,84146,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mcrpl-Macroprolactin, Serum",3018414603,CDM,301,RC,84146,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Assay Of Prostaglandin (Ref Lab),3018415001,CDM,301,RC,84150,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Assay Of Prostaglandin (Ref Lab),3018415001,CDM,301,RC,84150,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Prostaglandin D2 (Pgd2) (Ref Lab),3018415002,CDM,301,RC,84150,HCPCS,,,facility,both,,,,369,276.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prostaglandin D2 (Pgd2) (Ref Lab),3018415002,CDM,301,RC,84150,HCPCS,,,facility,both,,,,369,276.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Prostaglandin D2 (Pgd2), U (Ref Lab)",3018415003,CDM,301,RC,84150,HCPCS,,,facility,both,,,,428,321,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Prostaglandin D2 (Pgd2), U (Ref Lab)",3018415003,CDM,301,RC,84150,HCPCS,,,facility,both,,,,428,321,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo 23Bpr-Assay Of Prostaglandin,3018415004,CDM,301,RC,84150,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prostate-Specific Antigen,3018415301,CDM,301,RC,84153,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prostate-Specific Antigen,3018415301,CDM,301,RC,84153,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Prostate-Specific Antigen,3018415301,CDM,301,RC,84153,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Prostate-Specific Antigen,3018415301,CDM,301,RC,84153,HCPCS,,,facility,both,,,,12.81,9.61,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Prostate-Specific Antigen,3018415301,CDM,301,RC,84153,HCPCS,,,facility,both,,,,20.23,15.17,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Prostate Specific Ag, Total (Ref Lab)",3018415302,CDM,301,RC,84153,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Prostate Specific Ag, Total (Ref Lab)",3018415302,CDM,301,RC,84153,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Psa Ultrasensitive, Serum (Ref Lab)",3018415303,CDM,301,RC,84153,HCPCS,,,facility,both,,,,185,138.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Psa Ultrasensitive, Serum (Ref Lab)",3018415303,CDM,301,RC,84153,HCPCS,,,facility,both,,,,149,111.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Prostate Health Index (Phi), Serum (Ref Lab)",3018415304,CDM,301,RC,84153,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Prostate Health Index (Phi), Serum (Ref Lab)",3018415304,CDM,301,RC,84153,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Psaft Assay Of Psa Total,3018415305,CDM,301,RC,84153,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Prostate Specific Ag, Free (Ref Lab)",3018415401,CDM,301,RC,84154,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Prostate Specific Ag, Free (Ref Lab)",3018415401,CDM,301,RC,84154,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Psaft Assay Of Psa Free,3018415402,CDM,301,RC,84154,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Phi13-Prostate Health Index Reflex: Free Psa,3018415403,CDM,301,RC,84154,HCPCS,,,facility,both,,,,180,135,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Phi13-Prostate Health Index Reflex: Free Psa,3018415403,CDM,301,RC,84154,HCPCS,,,facility,both,,,,180,135,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Protein, Total, Serum",3018415501,CDM,301,RC,84155,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Protein, Total, Serum",3018415501,CDM,301,RC,84155,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Protein, Total, Serum",3018415501,CDM,301,RC,84155,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Protein, Total, Serum",3018415501,CDM,301,RC,84155,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Total Protein (Ref Lab),3018415502,CDM,301,RC,84155,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Total Protein (Ref Lab),3018415502,CDM,301,RC,84155,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Peiso Assay Of Protein Serum,3018415503,CDM,301,RC,84155,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Peiso Assay Of Protein Serum,3018415503,CDM,301,RC,84155,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Spep Assay Of Protein Serum,3018415504,CDM,301,RC,84155,HCPCS,,,facility,both,,,,4.33,3.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Spep Assay Of Protein Serum,3018415504,CDM,301,RC,84155,HCPCS,,,facility,both,,,,4.33,3.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dmoga Assay Of Protein Serum,3018415505,CDM,301,RC,84155,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dmoga Assay Of Protein Serum,3018415505,CDM,301,RC,84155,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fmnpp-Total Protein Level, Blood",3018415506,CDM,301,RC,84155,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fmnpp-Total Protein Level, Blood",3018415506,CDM,301,RC,84155,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Protein, Total, Urine",3018415601,CDM,301,RC,84156,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Protein, Total, Urine",3018415601,CDM,301,RC,84156,HCPCS,,,facility,both,,,,4.37,3.28,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Protein, Total, Urine",3018415601,CDM,301,RC,84156,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Protein, Total, U (Ref Lab)",3018415602,CDM,301,RC,84156,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Epu Assay Of Protein Urine,3018415603,CDM,301,RC,84156,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Epu Assay Of Protein Urine,3018415603,CDM,301,RC,84156,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Mpsu Assay Of Protein Urine,3018415604,CDM,301,RC,84156,HCPCS,,,facility,both,,,,4.33,3.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Mpsu Assay Of Protein Urine,3018415604,CDM,301,RC,84156,HCPCS,,,facility,both,,,,4.33,3.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Repu Assay Of Protein Urine,3018415605,CDM,301,RC,84156,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Repu Assay Of Protein Urine,3018415605,CDM,301,RC,84156,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rmpsu Assay Of Protein Urine,3018415606,CDM,301,RC,84156,HCPCS,,,facility,both,,,,4.33,3.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rmpsu Assay Of Protein Urine,3018415606,CDM,301,RC,84156,HCPCS,,,facility,both,,,,4.33,3.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fiflc-Free Urinary Kappa Light Chains,3018415607,CDM,301,RC,84156,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fiflc-Free Urinary Kappa Light Chains,3018415607,CDM,301,RC,84156,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Rmpqu/Rptu2-Protein, Random, Urine",3018415608,CDM,301,RC,84156,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Rmpqu/Rptu2-Protein, Random, Urine",3018415608,CDM,301,RC,84156,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Protein, Total, Csf",3018415701,CDM,301,RC,84157,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Protein, Total, Csf",3018415701,CDM,301,RC,84157,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Protein, Total, Csf",3018415701,CDM,301,RC,84157,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Protein, Total, Body Fluid",3018415702,CDM,301,RC,84157,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Protein, Total, Body Fluid",3018415702,CDM,301,RC,84157,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Protein, Total, Body Fluid",3018415702,CDM,301,RC,84157,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Protein, Total, Body Fluid",3018415702,CDM,301,RC,84157,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Mayo Zw242-Protein, Total, Except By Refractometry; Other Source (Eg, Synovial Fluid, Cerebrospin",3018415703,CDM,301,RC,84157,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Tpsf-Protein, Total, Except By Refractometry; Other Source (Eg, Synovial Fluid, Cerebrospina",3018415704,CDM,301,RC,84157,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Electrophoresis, Protein,Serum (Ref Lab)",3018416501,CDM,301,RC,84165,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Electrophoresis, Protein,Serum (Ref Lab)",3018416501,CDM,301,RC,84165,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Protein Electrophoresis (Ref Lab),3018416502,CDM,301,RC,84165,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Protein Electrophoresis (Ref Lab),3018416502,CDM,301,RC,84165,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Peiso Protein E-Phoresis Serum,3018416503,CDM,301,RC,84165,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Peiso Protein E-Phoresis Serum,3018416503,CDM,301,RC,84165,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Spep Protein E-Phoresis Serum,3018416504,CDM,301,RC,84165,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Spep Protein E-Phoresis Serum,3018416504,CDM,301,RC,84165,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dmoga Protein E-Phoresis Serum,3018416505,CDM,301,RC,84165,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dmoga Protein E-Phoresis Serum,3018416505,CDM,301,RC,84165,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fmnpp-Protein Measurement, Serum",3018416507,CDM,301,RC,84165,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fmnpp-Protein Measurement, Serum",3018416507,CDM,301,RC,84165,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Electrophoresis, Urine,Random (Ref Lab)",3018416601,CDM,301,RC,84166,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Electrophoresis, Urine,Random (Ref Lab)",3018416601,CDM,301,RC,84166,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Protein; E-Phoresis, Other Fld (Ref Lab)",3018416602,CDM,301,RC,84166,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Protein Electrophoresis, U (Ref Lab)",3018416603,CDM,301,RC,84166,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Protein Electrophoresis, U (Ref Lab)",3018416603,CDM,301,RC,84166,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Epu Protein E-Phoresis/Urine/Csf,3018416604,CDM,301,RC,84166,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Epu Protein E-Phoresis/Urine/Csf,3018416604,CDM,301,RC,84166,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Mpsu Protein E-Phoresis/Urine/Csf,3018416605,CDM,301,RC,84166,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Mpsu Protein E-Phoresis/Urine/Csf,3018416605,CDM,301,RC,84166,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Repu Protein E-Phoresis/Urine/Csf,3018416606,CDM,301,RC,84166,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Repu Protein E-Phoresis/Urine/Csf,3018416606,CDM,301,RC,84166,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rmpsu Protein E-Phoresis/Urine/Csf,3018416607,CDM,301,RC,84166,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rmpsu Protein E-Phoresis/Urine/Csf,3018416607,CDM,301,RC,84166,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Rmpqu/Rpeu-Protein Electrophoresis, Random, Urine",3018416609,CDM,301,RC,84166,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Rmpqu/Rpeu-Protein Electrophoresis, Random, Urine",3018416609,CDM,301,RC,84166,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mag W/Rflx Mag-Sgpg & Mag, Eia (Ref Lab)",3018418101,CDM,301,RC,84181,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Crmp-5-Igg Western Blot (Ref Lab),3018418201,CDM,301,RC,84182,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc 68Kd(Hsp-70) Heatshock Protein (Ref Lab),3018418202,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc 68Kd(Hsp-70) Heatshock Protein (Ref Lab),3018418202,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc National Prion 14-3-3 Protein (Ref Lab),3018418203,CDM,301,RC,84182,HCPCS,,,facility,both,,,,195,146.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc National Prion 14-3-3 Protein (Ref Lab),3018418203,CDM,301,RC,84182,HCPCS,,,facility,both,,,,195,146.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Nmo/Aqp4 Facs, S",3018418204,CDM,301,RC,84182,HCPCS,,,facility,both,,,,282,211.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Nmo/Aqp4 Facs, S",3018418204,CDM,301,RC,84182,HCPCS,,,facility,both,,,,282,211.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Amibs-Amphiphysin Immunoblot, Serum",3018418205,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Amibs-Amphiphysin Immunoblot, Serum",3018418205,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  An1Bs-Anna-1 Immunoblot, Serum",3018418206,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  An1Bs-Anna-1 Immunoblot, Serum",3018418206,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  An2Bs-Anna-2 Immunoblot, Serum",3018418207,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  An2Bs-Anna-2 Immunoblot, Serum",3018418207,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Crmws-Crmp-5-Igg Western Blot, Serum",3018418208,CDM,301,RC,84182,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Crmws-Crmp-5-Igg Western Blot, Serum",3018418208,CDM,301,RC,84182,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Pc1Bs-Pca-1 Immunoblot, Serum",3018418209,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Pc1Bs-Pca-1 Immunoblot, Serum",3018418209,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Pctbs-Pca-Tr Immunoblot, Serum",3018418210,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Pctbs-Pca-Tr Immunoblot, Serum",3018418210,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Agnbs-Ens 2 Reflex: Antiglial/Neuronal Nuclear Antibody-Type,1?? Immunoblot, Serum",3018418211,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Agnbs-Ens 2 Reflex: Antiglial/Neuronal Nuclear Antibody-Type,1?? Immunoblot, Serum",3018418211,CDM,301,RC,84182,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mds2-Protein Westrn Blot Blood/Oth Flu Immunological,3018418212,CDM,301,RC,84182,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mac1 - Protein; Western Blot, With Interpretation And Report, Blood Or Other Body Fluid, Imm",3018418213,CDM,301,RC,84182,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mac1 - Protein; Western Blot, With Interpretation And Report, Blood Or Other Body Fluid, Imm",3018418213,CDM,301,RC,84182,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Proinsulin, Plasma (Ref Lab)",3018420601,CDM,301,RC,84206,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Proinsulin, Plasma (Ref Lab)",3018420601,CDM,301,RC,84206,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pyridoxal 5-Phosphate (Plp) B6 (Ref Lab),3018420701,CDM,301,RC,84207,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pyridoxal 5-Phosphate (Plp) B6 (Ref Lab),3018420701,CDM,301,RC,84207,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo B6Pro Assay Of Vitamin B-6,3018420702,CDM,301,RC,84207,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo B6Pro Assay Of Vitamin B-6,3018420702,CDM,301,RC,84207,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pyruvic Acid (Ref Lab),3018421001,CDM,301,RC,84210,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pyruvic Acid (Ref Lab),3018421001,CDM,301,RC,84210,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Pyruvate Kinase, Erythrocytes (Ref Lab)",3018422001,CDM,301,RC,84220,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pyruvate Kinase, Erythrocytes (Ref Lab)",3018422001,CDM,301,RC,84220,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Haev1-Assay Of Pyruvate Kinase,3018422002,CDM,301,RC,84220,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Assay Of Pyruvate Kinase,3018422002,CDM,301,RC,84220,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Transferrin Receptor Assay (Ref Lab),3018423801,CDM,301,RC,84238,HCPCS,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Transferrin Receptor Assay (Ref Lab),3018423801,CDM,301,RC,84238,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Renin (Plasma) (Ref Lab),3018424401,CDM,301,RC,84244,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Renin (Plasma) (Ref Lab),3018424401,CDM,301,RC,84244,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Riboflavin (Vitamin B2) (Ref Lab),3018425201,CDM,301,RC,84252,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Riboflavin (Vitamin B2) (Ref Lab),3018425201,CDM,301,RC,84252,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Selenium, Blood (Ref Lab)",3018425501,CDM,301,RC,84255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Selenium, Blood (Ref Lab)",3018425501,CDM,301,RC,84255,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Serotonin (Ref Lab),3018426001,CDM,301,RC,84260,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Serotonin (Ref Lab),3018426001,CDM,301,RC,84260,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Sex Hormone Binging Globulin (Ref Lab),3018427001,CDM,301,RC,84270,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sex Hormone Binging Globulin (Ref Lab),3018427001,CDM,301,RC,84270,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ffes-Sex Hormone Binding Globulin (Protein) Level,3018427003,CDM,301,RC,84270,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ffes-Sex Hormone Binding Globulin (Protein) Level,3018427003,CDM,301,RC,84270,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sodium, Serum",3018429501,CDM,301,RC,84295,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sodium, Serum",3018429501,CDM,301,RC,84295,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sodium, Serum",3018429501,CDM,301,RC,84295,HCPCS,,,facility,both,,,,7.26,5.44,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Sodium, Serum",3018429501,CDM,301,RC,84295,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Sodium, Poc",3018429502,CDM,301,RC,84295,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sodium, Urine",3018430001,CDM,301,RC,84300,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sodium, Urine",3018430001,CDM,301,RC,84300,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sodium, Urine",3018430001,CDM,301,RC,84300,HCPCS,,,facility,both,,,,7.26,5.44,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Sodium, Urine, 24 Hour  (Ref Lab)",3018430002,CDM,301,RC,84300,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sodium, Urine, 24 Hour  (Ref Lab)",3018430002,CDM,301,RC,84300,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Sodium,3018430003,CDM,301,RC,84300,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Sodium,3018430003,CDM,301,RC,84300,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sodium, F (Ref Lab)",3018430201,CDM,301,RC,84302,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sodium, F (Ref Lab)",3018430201,CDM,301,RC,84302,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Efpo Assay Of Sweat Sodium,3018430202,CDM,301,RC,84302,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Efpo Assay Of Sweat Sodium,3018430202,CDM,301,RC,84302,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Osg_F-Sodium Level,3018430203,CDM,301,RC,84302,HCPCS,,,facility,both,,,,172,129,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Osg_F-Sodium Level,3018430203,CDM,301,RC,84302,HCPCS,,,facility,both,,,,172,129,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Insulin Like Growth Factor 1 (Ref Lab),3018430501,CDM,301,RC,84305,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insulin Like Growth Factor 1 (Ref Lab),3018430501,CDM,301,RC,84305,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fsoma-Assay Of Somatostatin,3018430701,CDM,301,RC,84307,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fsoma-Assay Of Somatostatin,3018430701,CDM,301,RC,84307,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Galactose-1-Phosphate (Ref Lab),3018431101,CDM,301,RC,84311,HCPCS,,,facility,both,,,,195,146.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Adenosine Deaminase, Pleural F (Ref Lab)",3018431102,CDM,301,RC,84311,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Adenosine Deaminase Peritoneal (Ref Lab),3018431103,CDM,301,RC,84311,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Adenosine Deaminase Peritoneal (Ref Lab),3018431103,CDM,301,RC,84311,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Spectrophotometry (Ref Lab),3018431104,CDM,301,RC,84311,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Adenosine Deaminase, Rbc (Ref Lab)",3018431105,CDM,301,RC,84311,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Porphyrins, Total, Plasma (Ref Lab)",3018431106,CDM,301,RC,84311,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Porphyrins, Total, Plasma (Ref Lab)",3018431106,CDM,301,RC,84311,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Csu-Spectrophotometry, Analyte Not Elsewhere Specified",3018431107,CDM,301,RC,84311,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Csu-Spectrophotometry, Analyte Not Elsewhere Specified",3018431107,CDM,301,RC,84311,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Chlbf-Cholesterol, Body Fluid",3018431108,CDM,301,RC,84311,HCPCS,,,facility,both,,,,209,156.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Chlbf-Cholesterol, Body Fluid",3018431108,CDM,301,RC,84311,HCPCS,,,facility,both,,,,209,156.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Pee- Chemical Analysis Using Spectrophotometry (Light),3018431109,CDM,301,RC,84311,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Uredf-Sugars Mono Di&Oligos 1 Qualitataive Each Spec,3018437601,CDM,301,RC,84376,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Uredf-Sugars Mono Di&Oligos 1 Qualitataive Each Spec,3018437601,CDM,301,RC,84376,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sulfate, 24 Hour, Urine (Ref Lab)",3018439201,CDM,301,RC,84392,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sulfate, 24 Hour, Urine (Ref Lab)",3018439201,CDM,301,RC,84392,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Sulfate,3018439202,CDM,301,RC,84392,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine Sulfate,3018439202,CDM,301,RC,84392,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Free Testosterone (Ref Lab),3018440201,CDM,301,RC,84402,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Free Testosterone (Ref Lab),3018440201,CDM,301,RC,84402,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Testosterone, Free (Ref Lab)",3018440202,CDM,301,RC,84402,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Testosterone, Free (Ref Lab)",3018440202,CDM,301,RC,84402,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tgrp Assay Of Free Testosterone,3018440203,CDM,301,RC,84402,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tgrp Assay Of Free Testosterone,3018440203,CDM,301,RC,84402,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ttfb Assay Of Free Testosterone,3018440204,CDM,301,RC,84402,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ttfb Assay Of Free Testosterone,3018440204,CDM,301,RC,84402,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Testosterone, Total (Ref Lab)",3018440301,CDM,301,RC,84403,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Testosterone, Total (Ref Lab)",3018440301,CDM,301,RC,84403,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Total Testosterone (Ref Lab),3018440302,CDM,301,RC,84403,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Total Testosterone (Ref Lab),3018440302,CDM,301,RC,84403,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Testosterone, Total (Ref Lab)",3018440303,CDM,301,RC,84403,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Testosterone, Total (Ref Lab)",3018440303,CDM,301,RC,84403,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tgrp Assay Of Total Testosterone,3018440304,CDM,301,RC,84403,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tgrp Assay Of Total Testosterone,3018440304,CDM,301,RC,84403,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ttfb Assay Of Total Testosterone,3018440305,CDM,301,RC,84403,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ttfb Assay Of Total Testosterone,3018440305,CDM,301,RC,84403,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Assay Of Testosterone Total,3018440306,CDM,301,RC,84403,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Assay Of Testosterone Total,3018440306,CDM,301,RC,84403,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Testosterone, Bioavailable (Ref Lab)",3018441001,CDM,301,RC,84410,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Testosterone, Bioavailable (Ref Lab)",3018441001,CDM,301,RC,84410,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ttfb Testosterone Bioavailable,3018441002,CDM,301,RC,84410,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ttfb Testosterone Bioavailable,3018441002,CDM,301,RC,84410,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vitamin B-1 (Ref Lab),3018442501,CDM,301,RC,84425,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vitamin B-1 (Ref Lab),3018442501,CDM,301,RC,84425,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Tgms-Thyroglobulin Mass Spec,S (Ref Lab)",3018443201,CDM,301,RC,84432,HCPCS,,,facility,both,,,,241,180.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tgms-Thyroglobulin Mass Spec,S (Ref Lab)",3018443201,CDM,301,RC,84432,HCPCS,,,facility,both,,,,241,180.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Thyroglobulin, Tumor Marker Ia (Ref Lab)",3018443202,CDM,301,RC,84432,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Thyroglobulin, Tumor Marker Ia (Ref Lab)",3018443202,CDM,301,RC,84432,HCPCS,,,facility,both,,,,88,66,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Thyroglobulin,Fna Lymph Node (Ref Lab)",3018443203,CDM,301,RC,84432,HCPCS,,,facility,both,,,,276,207,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Thyroglobulin,Fna Lymph Node (Ref Lab)",3018443203,CDM,301,RC,84432,HCPCS,,,facility,both,,,,276,207,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc T-4, Thyroxine, Total",3018443601,CDM,301,RC,84436,HCPCS,,,facility,both,,,,8.32,6.24,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc T-4, Thyroxine, Total",3018443601,CDM,301,RC,84436,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc T-4, Thyroxine, Total",3018443601,CDM,301,RC,84436,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc T-4, Thyroxine, Total",3018443601,CDM,301,RC,84436,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc T-4, Thyroxine, Total",3018443601,CDM,301,RC,84436,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc T4, Total (Ref Lab)",3018443602,CDM,301,RC,84436,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc T4, Total (Ref Lab)",3018443602,CDM,301,RC,84436,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Frtup Assay Of Total Thyroxine,3018443603,CDM,301,RC,84436,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Frtup Assay Of Total Thyroxine,3018443603,CDM,301,RC,84436,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh T4,3018443604,CDM,301,RC,84436,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh T4,3018443604,CDM,301,RC,84436,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Free T4,3018443605,CDM,301,RC,84436,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Free T4,3018443605,CDM,301,RC,84436,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Free T4,3018443901,CDM,301,RC,84439,HCPCS,,,facility,both,,,,127,95.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Free T4,3018443901,CDM,301,RC,84439,HCPCS,,,facility,both,,,,95.16,71.37,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Free T4,3018443901,CDM,301,RC,84439,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Free T4,3018443901,CDM,301,RC,84439,HCPCS,,,facility,both,,,,9.92,7.44,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Free T4,3018443901,CDM,301,RC,84439,HCPCS,,,facility,both,,,,2.4,1.8,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc T4 (Thyroxine), Free, S (Ref Lab)",3018443902,CDM,301,RC,84439,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc T4 (Thyroxine), Free, S (Ref Lab)",3018443902,CDM,301,RC,84439,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Thyroxine Binding Globulin (Ref Lab),3018444201,CDM,301,RC,84442,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thyroxine Binding Globulin (Ref Lab),3018444201,CDM,301,RC,84442,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tsh,3018444301,CDM,301,RC,84443,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tsh,3018444301,CDM,301,RC,84443,HCPCS,,,facility,both,,,,111.38,83.54,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Tsh,3018444301,CDM,301,RC,84443,HCPCS,,,facility,both,,,,14.27,10.7,,,,,,,,,,"Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Tsh,3018444301,CDM,301,RC,84443,HCPCS,,,facility,both,,,,18.48,13.86,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Tsh,3018444301,CDM,301,RC,84443,HCPCS,,,facility,both,,,,3.07,2.3,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Kh Mayo  Stsh-Thyroid-Stimulating Hormone-Sensitive (S-Tsh), Serum",3018444302,CDM,301,RC,84443,HCPCS,,,facility,both,,,,123,92.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Stsh-Thyroid-Stimulating Hormone-Sensitive (S-Tsh), Serum",3018444302,CDM,301,RC,84443,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Tsh,3018444303,CDM,301,RC,84443,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Tsh,3018444303,CDM,301,RC,84443,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Tsh,3018444304,CDM,301,RC,84443,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Tsh,3018444304,CDM,301,RC,84443,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fcuip-Blood Test, Thyroid Stimulating Hormone (Tsh)",3018444305,CDM,301,RC,84443,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fcuip-Blood Test, Thyroid Stimulating Hormone (Tsh)",3018444305,CDM,301,RC,84443,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Thyroid Stimulating Immunoglob (Ref Lab),3018444501,CDM,301,RC,84445,HCPCS,,,facility,both,,,,177,132.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thyroid Stimulating Immunoglob (Ref Lab),3018444501,CDM,301,RC,84445,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vitamin E (Ref Lab),3018444601,CDM,301,RC,84446,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vitamin E (Ref Lab),3018444601,CDM,301,RC,84446,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vitamin E (Ref Lab),3018444602,CDM,301,RC,84446,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vitamin E (Ref Lab),3018444602,CDM,301,RC,84446,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Vitae Assay Of Vitamin E,3018444603,CDM,301,RC,84446,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Vitae Assay Of Vitamin E,3018444603,CDM,301,RC,84446,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw59-Assay Of Transcortin Cortisol Binding Globulin,3018444901,CDM,301,RC,84449,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw59-Assay Of Transcortin Cortisol Binding Globulin,3018444901,CDM,301,RC,84449,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ast/Sgot,3018445001,CDM,301,RC,84450,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ast/Sgot,3018445001,CDM,301,RC,84450,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ast/Sgot,3018445001,CDM,301,RC,84450,HCPCS,,,facility,both,,,,7.81,5.86,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Ast/Sgot,3018445001,CDM,301,RC,84450,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Neonate Chem Ast,3018445002,CDM,301,RC,84450,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Chem Ast,3018445002,CDM,301,RC,84450,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Alt/Sgpt,3018446001,CDM,301,RC,84460,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Alt/Sgpt,3018446001,CDM,301,RC,84460,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Alt/Sgpt,3018446001,CDM,301,RC,84460,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Alt/Sgpt,3018446001,CDM,301,RC,84460,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Neonate Chem Alt,3018446002,CDM,301,RC,84460,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Chem Alt,3018446002,CDM,301,RC,84460,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Alanine Aminotransferase (Alt) (Gpt), Serum (Ref Lab)",3018446003,CDM,301,RC,84460,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Alanine Aminotransferase (Alt) (Gpt), Serum (Ref Lab)",3018446003,CDM,301,RC,84460,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Transferrin (Ref Lab),3018446601,CDM,301,RC,84466,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Transferrin (Ref Lab),3018446601,CDM,301,RC,84466,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Transferrin (Ref Lab),3018446601,CDM,301,RC,84466,HCPCS,,,facility,both,,,,15.23,11.42,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Triglycerides,3018447801,CDM,301,RC,84478,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Triglycerides,3018447801,CDM,301,RC,84478,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Triglycerides,3018447801,CDM,301,RC,84478,HCPCS,,,facility,both,,,,6.31,4.73,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Triglycerides,3018447801,CDM,301,RC,84478,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Neonate Chem Trig,3018447802,CDM,301,RC,84478,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Chem Trig,3018447802,CDM,301,RC,84478,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Triglycerides (Ref Lab),3018447803,CDM,301,RC,84478,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Triglycerides (Ref Lab),3018447803,CDM,301,RC,84478,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Csu-Triglycerides,3018447804,CDM,301,RC,84478,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Csu-Triglycerides,3018447804,CDM,301,RC,84478,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Lmpp-Triglycerides, Cdc, S",3018447805,CDM,301,RC,84478,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Lmpp-Triglycerides, Cdc, S",3018447805,CDM,301,RC,84478,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Crmp1-Assay Of Triglycerides,3018447806,CDM,301,RC,84478,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T3 Uptake (Ref Lab),3018447902,CDM,301,RC,84479,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T3 Uptake (Ref Lab),3018447902,CDM,301,RC,84479,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Frtup Assay Of Thyroid (T3 Or T4),3018447903,CDM,301,RC,84479,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Frtup Assay Of Thyroid (T3 Or T4),3018447903,CDM,301,RC,84479,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw59-Thyroid Hormone Evaluation,3018447904,CDM,301,RC,84479,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw59-Thyroid Hormone Evaluation,3018447904,CDM,301,RC,84479,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc T-3, Triiodothyronine",3018448001,CDM,301,RC,84480,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc T-3, Triiodothyronine",3018448001,CDM,301,RC,84480,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc T-3, Triiodothyronine",3018448001,CDM,301,RC,84480,HCPCS,,,facility,both,,,,12.7,9.52,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc T-3, Triiodothyronine",3018448001,CDM,301,RC,84480,HCPCS,,,facility,both,,,,18.63,13.97,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc T3 Triiodothyronine), Total, S (Ref Lab)",3018448002,CDM,301,RC,84480,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc T3 Triiodothyronine), Total, S (Ref Lab)",3018448002,CDM,301,RC,84480,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Triiodothyronine T3, Free",3018448101,CDM,301,RC,84481,HCPCS,,,facility,both,,,,3.57,2.68,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Triiodothyronine T3, Free",3018448101,CDM,301,RC,84481,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Triiodothyronine T3, Free",3018448101,CDM,301,RC,84481,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Triiodothyronine T3, Free",3018448101,CDM,301,RC,84481,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Triiodothyronine T3, Free",3018448101,CDM,301,RC,84481,HCPCS,,,facility,both,,,,18.63,13.97,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc T3, Free (Ref Lab)",3018448102,CDM,301,RC,84481,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc T3, Free (Ref Lab)",3018448102,CDM,301,RC,84481,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc T-3 Reverse (Ref Lab),3018448201,CDM,301,RC,84482,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-3 Reverse (Ref Lab),3018448201,CDM,301,RC,84482,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Troponin, Quantitative",3018448401,CDM,301,RC,84484,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Troponin, Quantitative",3018448401,CDM,301,RC,84484,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Troponin, Quantitative",3018448401,CDM,301,RC,84484,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Troponin, Quantitative",3018448401,CDM,301,RC,84484,HCPCS,,,facility,both,,,,14.85,11.14,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Troponin, Quantitative",3018448401,CDM,301,RC,84484,HCPCS,,,facility,both,,,,6.93,5.2,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Troponin I, Serum (Ref Lab)",3018448402,CDM,301,RC,84484,HCPCS,,,facility,both,,,,192,144,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Troponin I, Serum (Ref Lab)",3018448402,CDM,301,RC,84484,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bun (Urea Nitrogen), Quant",3018452001,CDM,301,RC,84520,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bun (Urea Nitrogen), Quant",3018452001,CDM,301,RC,84520,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bun (Urea Nitrogen), Quant",3018452001,CDM,301,RC,84520,HCPCS,,,facility,both,,,,14.8,11.1,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Bun (Urea Nitrogen), Quant",3018452001,CDM,301,RC,84520,HCPCS,,,facility,both,,,,5.96,4.47,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Bun (Urea Nitrogen), Quant",3018452001,CDM,301,RC,84520,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Urea Nitrogen, Urine",3018454001,CDM,301,RC,84540,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Urea Nitrogen, Urine",3018454001,CDM,301,RC,84540,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Urea Nitrogen, Urine",3018454001,CDM,301,RC,84540,HCPCS,,,facility,both,,,,5.96,4.47,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Urea Nitrogen, Urine, 24 Hour  (Ref Lab)",3018454002,CDM,301,RC,84540,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Urea Nitrogen, Urine, 24 Hour  (Ref Lab)",3018454002,CDM,301,RC,84540,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine/Urea-N,3018454003,CDM,301,RC,84540,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine/Urea-N,3018454003,CDM,301,RC,84540,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Urea Clearance, Urine, 24 Hour",3018454501,CDM,301,RC,84545,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Urea Clearance, Urine, 24 Hour",3018454501,CDM,301,RC,84545,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Urea Clearance, Urine, 24 Hour",3018454501,CDM,301,RC,84545,HCPCS,,,facility,both,,,,7.92,5.94,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Uric Acid, Blood",3018455001,CDM,301,RC,84550,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Uric Acid, Blood",3018455001,CDM,301,RC,84550,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Uric Acid, Blood",3018455001,CDM,301,RC,84550,HCPCS,,,facility,both,,,,4.97,3.73,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Uric Acid, Blood",3018455001,CDM,301,RC,84550,HCPCS,,,facility,both,,,,1.98,1.48,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Uric Acid, Other Source",3018456001,CDM,301,RC,84560,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Uric Acid, Other Source",3018456001,CDM,301,RC,84560,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Uric Acid, Other Source",3018456001,CDM,301,RC,84560,HCPCS,,,facility,both,,,,42.6,31.95,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Uric Acid, Other Source",3018456001,CDM,301,RC,84560,HCPCS,,,facility,both,,,,4.97,3.73,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Uric Acid, Urine, 24 Hour  (Ref Lab)",3018456002,CDM,301,RC,84560,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Uric Acid, Urine, 24 Hour  (Ref Lab)",3018456002,CDM,301,RC,84560,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine/Uric Acid,3018456003,CDM,301,RC,84560,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Sup24 Assay Of Urine/Uric Acid,3018456003,CDM,301,RC,84560,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vanillylmandelic Acid 24H Urin (Ref Lab),3018458501,CDM,301,RC,84585,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vanillylmandelic Acid 24H Urin (Ref Lab),3018458501,CDM,301,RC,84585,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Vma-Vanillylmandelic Acid,3018458502,CDM,301,RC,84585,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Vma-Vanillylmandelic Acid,3018458502,CDM,301,RC,84585,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Tramadol And Metabolite, Random, Urine (Ref Lab)",3018458601,CDM,301,RC,84586,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tramadol And Metabolite, Random, Urine (Ref Lab)",3018458601,CDM,301,RC,84586,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vasoactive Intestinal Peptide (Vip) (Ref Lab),3018458602,CDM,301,RC,84586,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vasoactive Intestinal Peptide (Vip) (Ref Lab),3018458602,CDM,301,RC,84586,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fvip2-Assay Of Vasoactive Intestinal Peptide,3018458603,CDM,301,RC,84586,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fvip2-Assay Of Vasoactive Intestinal Peptide,3018458603,CDM,301,RC,84586,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cpavp-Assay Of Vasopressin Anti-Diuretic Hormone,3018458802,CDM,301,RC,84588,HCPCS,,,facility,both,,,,371,278.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vitamin A (Ref Lab),3018459001,CDM,301,RC,84590,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vitamin A (Ref Lab),3018459001,CDM,301,RC,84590,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vitamin A (Ref Lab),3018459002,CDM,301,RC,84590,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vitamin A (Ref Lab),3018459002,CDM,301,RC,84590,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Vitae Assay Of Vitamin A,3018459003,CDM,301,RC,84590,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Vitae Assay Of Vitamin A,3018459003,CDM,301,RC,84590,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Niacin (Ref Lab),3018459101,CDM,301,RC,84591,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Niacin (Ref Lab),3018459101,CDM,301,RC,84591,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Vitamin B7, H (Biotin) (Ref Lab)",3018459102,CDM,301,RC,84591,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vitamin B7, H (Biotin) (Ref Lab)",3018459102,CDM,301,RC,84591,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fpab-Pantothenic Acid (B-5) Bioassay,3018459103,CDM,301,RC,84591,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fpab-Pantothenic Acid (B-5) Bioassay,3018459103,CDM,301,RC,84591,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vitamin K (Ref Lab),3018459701,CDM,301,RC,84597,HCPCS,,,facility,both,,,,331,248.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vitamin K (Ref Lab),3018459701,CDM,301,RC,84597,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Zinc (Ref Lab),3018463001,CDM,301,RC,84630,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Zinc (Ref Lab),3018463001,CDM,301,RC,84630,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc C-Peptide, Serum (Ref Lab)",3018468101,CDM,301,RC,84681,HCPCS,,,facility,both,,,,170,127.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc C-Peptide, Serum (Ref Lab)",3018468101,CDM,301,RC,84681,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C-Peptide,3018468102,CDM,301,RC,84681,HCPCS,,,facility,both,,,,192,144,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C-Peptide,3018468102,CDM,301,RC,84681,HCPCS,,,facility,both,,,,192,144,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hcg, Quant",3018470201,CDM,301,RC,84702,HCPCS,,,facility,both,,,,204,153,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hcg, Quant",3018470201,CDM,301,RC,84702,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hcg, Quant",3018470201,CDM,301,RC,84702,HCPCS,,,facility,both,,,,19.29,14.47,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Hcg, Quant",3018470201,CDM,301,RC,84702,HCPCS,,,facility,both,,,,16.56,12.42,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Hcg, Quant",3018470201,CDM,301,RC,84702,HCPCS,,,facility,both,,,,4.08,3.06,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Beta-Human Chorionic Gonadotropin, Quantitative, Serum (Ref Lab)",3018470202,CDM,301,RC,84702,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Beta-Human Chorionic Gonadotropin, Quantitative, Serum (Ref Lab)",3018470202,CDM,301,RC,84702,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Potassium, F (Ref Lab)",3018499901,CDM,301,RC,84999,HCPCS,,,facility,both,,,,3.24,2.43,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Potassium, F (Ref Lab)",3018499901,CDM,301,RC,84999,HCPCS,,,facility,both,,,,3.24,2.43,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Osmolality, F (Ref Lab)",3018499902,CDM,301,RC,84999,HCPCS,,,facility,both,,,,3.24,2.43,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Osmolality, F (Ref Lab)",3018499902,CDM,301,RC,84999,HCPCS,,,facility,both,,,,3.24,2.43,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fluconazole (Diflucan) (Ref Lab),3018499903,CDM,301,RC,84999,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fluconazole (Diflucan) (Ref Lab),3018499903,CDM,301,RC,84999,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Voriconazole (Ref Lab),3018499904,CDM,301,RC,84999,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Voriconazole (Ref Lab),3018499904,CDM,301,RC,84999,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Prometheus - Anser Vdz (Outside Ref Lab),3018499905,CDM,301,RC,84999,HCPCS,,,facility,both,,,,2974,2230.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Adalimumab Level & Antibody (Outside Ref Lab),3018499906,CDM,301,RC,84999,HCPCS,,,facility,both,,,,2812,2109,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prometheus - Anser Ifx (Outside Ref Lab),3018499907,CDM,301,RC,84999,HCPCS,,,facility,both,,,,2974,2230.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Efpo Clinical Chemistry Test,3018499908,CDM,301,RC,84999,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Efpo Clinical Chemistry Test,3018499908,CDM,301,RC,84999,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Efpo Clinical Chemistry Test,3018499909,CDM,301,RC,84999,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Efpo Clinical Chemistry Test,3018499909,CDM,301,RC,84999,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Zw300-Karius Test For Pathogen,3018499910,CDM,301,RC,84999,HCPCS,,,facility,both,,,,2391,1793.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Zw300-Karius Test For Pathogen,3018499910,CDM,301,RC,84999,HCPCS,,,facility,both,,,,2391,1793.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Zw80-Cenobamate (Xcopri), Plasma",3018499911,CDM,301,RC,84999,HCPCS,,,facility,both,,,,154,115.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Zw80-Cenobamate (Xcopri), Plasma",3018499911,CDM,301,RC,84999,HCPCS,,,facility,both,,,,154,115.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Zw80-Cenobamate (Xcopri), Plasma",3018499912,CDM,301,RC,84999,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Zw80-Cenobamate (Xcopri), Plasma",3018499912,CDM,301,RC,84999,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Zw131-Adamts13 Activity W/Reflex To Inhibitor,3018499913,CDM,301,RC,84999,HCPCS,,,facility,both,,,,448,336,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Zw131-Adamts13 Activity W/Reflex To Inhibitor,3018499913,CDM,301,RC,84999,HCPCS,,,facility,both,,,,448,336,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fazpn-Azole Panel,3018499914,CDM,301,RC,84999,HCPCS,,,facility,both,,,,280,210,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fazpn-Azole Panel,3018499914,CDM,301,RC,84999,HCPCS,,,facility,both,,,,280,210,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fazpn Azole Panel,3018499915,CDM,301,RC,84999,HCPCS,,,facility,both,,,,280,210,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fazpn Azole Panel,3018499915,CDM,301,RC,84999,HCPCS,,,facility,both,,,,280,210,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Zw71 Interleukin 6 Fluid,3018499916,CDM,301,RC,84999,HCPCS,,,facility,both,,,,607,455.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Zw71 Interleukin 6 Fluid,3018499916,CDM,301,RC,84999,HCPCS,,,facility,both,,,,607,455.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Zw221-Baylor Miscellaneous Medical Genetics,3018499917,CDM,301,RC,84999,HCPCS,,,facility,both,,,,3373,2529.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Zw221-Baylor Miscellaneous Medical Genetics,3018499917,CDM,301,RC,84999,HCPCS,,,facility,both,,,,3373,2529.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Zw127-Lrp4 Autoantibody Test,3018499918,CDM,301,RC,84999,HCPCS,,,facility,both,,,,994,745.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Zw127-Lrp4 Autoantibody Test,3018499918,CDM,301,RC,84999,HCPCS,,,facility,both,,,,994,745.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Zw196-Acid-Fast Bacilli (Afb) Identification,3018499919,CDM,301,RC,84999,HCPCS,,,facility,both,,,,491,368.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Zw196-Acid-Fast Bacilli (Afb) Identification,3018499919,CDM,301,RC,84999,HCPCS,,,facility,both,,,,491,368.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Zw119-Miscellaneous University Of Florida Testing,3018499920,CDM,301,RC,84999,HCPCS,,,facility,both,,,,204,153,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Zw119-Miscellaneous University Of Florida Testing,3018499920,CDM,301,RC,84999,HCPCS,,,facility,both,,,,204,153,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Zw242-Insulin, Free And Total",3018499921,CDM,301,RC,84999,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Zw242-Insulin, Free And Total",3018499921,CDM,301,RC,84999,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Osg_F-Osmotic Gap, Fluid",3018499922,CDM,301,RC,84999,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Osg_F-Osmotic Gap, Fluid",3018499922,CDM,301,RC,84999,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw59 - Unlisted Chemistry Procedure: Corticosteroid Binding Globulin,3018499923,CDM,301,RC,84999,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw59 - Unlisted Chemistry Procedure: Corticosteroid Binding Globulin,3018499923,CDM,301,RC,84999,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw51-Unlisted Chemistry Procedure: Disopyramide,3018499924,CDM,301,RC,84999,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw51-Unlisted Chemistry Procedure: Disopyramide,3018499924,CDM,301,RC,84999,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Cjde-Unlisted Chemistry Procedure: Cjd Evaluation, Csf",3018499925,CDM,301,RC,84999,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
PRAVASTATIN 10 MG TABS,30191,CDM,250,RC,904589161,NDC,,,facility,both,0.5,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG TABS,30191,CDM,250,RC,904589161,NDC,,,facility,both,4,UN,,2.66,2,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG TABS,30191,CDM,250,RC,904589161,NDC,,,facility,both,1,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,60687017801,NDC,,,facility,both,2,UN,,4.75,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,904589261,NDC,,,facility,both,4,UN,,3.11,2.33,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,51079045820,NDC,,,facility,both,1,UN,,9,6.75,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,904589261,NDC,,,facility,both,3,UN,,3.77,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,51079045820,NDC,,,facility,both,2,UN,,5.18,3.88,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,904589261,NDC,,,facility,both,2,UN,,5.08,3.81,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,60687017801,NDC,,,facility,both,0.5,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,904589261,NDC,,,facility,both,0.5,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,51079045820,NDC,,,facility,both,4,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,60687017801,NDC,,,facility,both,1,UN,,6.63,4.97,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,904589261,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG TABS,30192,CDM,250,RC,60687017801,NDC,,,facility,both,4,UN,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
"Hc Prostate Cancer Screening, Prostate Specific Antigen Test (Psa)",301G010301,CDM,301,RC,G0103,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Prostate Cancer Screening, Prostate Specific Antigen Test (Psa)",301G010301,CDM,301,RC,G0103,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Prostate Cancer Screening, Prostate Specific Antigen Test (Psa)",301G010301,CDM,301,RC,G0103,HCPCS,,,facility,both,,,,12.81,9.61,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Ethylene Glycol, Quant",301G048001,CDM,301,RC,G0480,HCPCS,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Bnzu-Benzodiazepines Confirmation, Urine",301G048003,CDM,301,RC,G0480,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Bnzu-Benzodiazepines Confirmation, Urine",301G048003,CDM,301,RC,G0480,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Newborn Metabolic Screening 1,301S362001,CDM,301,RC,S3620,HCPCS,,,facility,both,,,,196,147,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Newborn Metabolic Screening 1,301S362001,CDM,301,RC,S3620,HCPCS,,,facility,both,,,,196,147,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Newborn Metabolic Screening 2,301S362002,CDM,301,RC,S3620,HCPCS,,,facility,both,,,,334,250.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Newborn Metabolic Screening 3,301S362003,CDM,301,RC,S3620,HCPCS,,,facility,both,,,,334,250.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Syphilis Total Ab (Ref Lab),3020064U01,CDM,302,RC,0064U,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coronavirus 2/Flu/Rsv, Pcr",3020241U01,CDM,302,RC,0241U,HCPCS,,,facility,both,,,,343,257.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coronavirus 2/Flu/Rsv, Pcr",3020241U01,CDM,302,RC,0241U,HCPCS,,,facility,both,,,,343,257.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coronavirus 2/Flu/Rsv, Pcr",3020241U01,CDM,302,RC,0241U,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,68084020201,NDC,,,facility,both,3,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,904555960,NDC,,,facility,both,3,UN,,2.57,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,904555960,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,50268068615,NDC,,,facility,both,1,UN,,8.61,6.46,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,68084020201,NDC,,,facility,both,1,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,904555960,NDC,,,facility,both,4,UN,,2.06,1.55,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,50268068615,NDC,,,facility,both,4,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,904555960,NDC,,,facility,both,2,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,50268068615,NDC,,,facility,both,3,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,50268068615,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,68084020201,NDC,,,facility,both,2,UN,,5,3.75,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 50 MG TABS,30234,CDM,250,RC,50268068615,NDC,,,facility,both,0.5,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG SUPP,30270,CDM,250,RC,MHS1EA,HCPCS,713053612,NDC,facility,both,1,EA,,34.36,25.77,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG SUPP,30270,CDM,250,RC,MHS1EA,HCPCS,45802075830,NDC,facility,both,1,EA,,34.3,25.72,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG SUPP,30271,CDM,250,RC,713052612,NDC,,,facility,both,1,UN,,38.15,28.61,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG SUPP,30271,CDM,250,RC,45802075930,NDC,,,facility,both,1,UN,,31.25,23.44,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG SUPP,30271,CDM,250,RC,45802075930,NDC,,,facility,both,0.52,UN,,26.3,19.72,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,68180099801,NDC,,,facility,both,6,UN,,2.67,2,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,13668044370,NDC,,,facility,both,1,UN,,29.35,22.01,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,68180099801,NDC,,,facility,both,3,UN,,4.02,3.01,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,68180099801,NDC,,,facility,both,2,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,13668044370,NDC,,,facility,both,4,UN,,21.45,16.09,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,68180099801,NDC,,,facility,both,2.5,UN,,3.78,2.84,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,13668044370,NDC,,,facility,both,2,UN,,24.12,18.09,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,13668044370,NDC,,,facility,both,3,UN,,22.37,16.77,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,68180099801,NDC,,,facility,both,1,UN,,9.14,6.85,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,68180099801,NDC,,,facility,both,0.5,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,68180099801,NDC,,,facility,both,5,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG TABS,30275,CDM,250,RC,68180099801,NDC,,,facility,both,4,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN-HYDROCHLOROTHIAZIDE 300-12.5 MG TABS,30277,CDM,250,RC,93823256,NDC,,,facility,both,1,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN-HYDROCHLOROTHIAZIDE 300-12.5 MG TABS,30277,CDM,250,RC,54025513,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Kh Mayo  Adalx-Adalimumab Quantiative W/Reflex To Antibody,3028014502,CDM,302,RC,80145,HCPCS,,,facility,both,,,,414,310.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Adalx-Adalimumab Quantiative W/Reflex To Antibody,3028014502,CDM,302,RC,80145,HCPCS,,,facility,both,,,,360,270,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Etx-Ethosuximide, Serum",3028016801,CDM,302,RC,80168,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Etx-Ethosuximide, Serum",3028016801,CDM,302,RC,80168,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Posa-Posaconazole, Serum",3028018701,CDM,302,RC,80187,HCPCS,,,facility,both,,,,177,132.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Posa-Posaconazole, Serum",3028018701,CDM,302,RC,80187,HCPCS,,,facility,both,,,,177,132.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
PROPAFENONE 150 MG TABS,30281,CDM,250,RC,60687070911,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 150 MG TABS,30281,CDM,250,RC,591058201,NDC,,,facility,both,2,UN,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 150 MG TABS,30281,CDM,250,RC,60687070911,NDC,,,facility,both,0.5,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 150 MG TABS,30281,CDM,250,RC,60687070901,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 150 MG TABS,30281,CDM,250,RC,591058201,NDC,,,facility,both,1,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 150 MG TABS,30281,CDM,250,RC,59651025601,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 150 MG TABS,30281,CDM,250,RC,59651025601,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 225 MG TABS,30282,CDM,250,RC,59651025701,NDC,,,facility,both,1,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
"Hc Kh Mayo  Salct-Cortisol, Saliva",3028253305,CDM,302,RC,82533,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Salct-Cortisol, Saliva",3028253305,CDM,302,RC,82533,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Salct-Cortisol, Saliva",3028253306,CDM,302,RC,82533,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Salct-Cortisol, Saliva",3028253306,CDM,302,RC,82533,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Parathyroid Horm Related Prot (Ref Lab),3028351901,CDM,302,RC,83519,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calcium Channel Bind Ab,P/Q (Ref Lab)",3028351902,CDM,302,RC,83519,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calcium Channel Bind Ab,N Type (Ref Lab)",3028351903,CDM,302,RC,83519,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ach Receptor Binding Ab (Ref Lab),3028351904,CDM,302,RC,83519,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arbi (Ref Lab),3028351905,CDM,302,RC,83519,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arbi (Ref Lab),3028351905,CDM,302,RC,83519,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ach Receptor Binding Ab (Ref Lab),3028351906,CDM,302,RC,83519,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Achr Ganglionic Neuronal Ab (Ref Lab),3028351907,CDM,302,RC,83519,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuronal Vgkc Auto Ab (Ref Lab),3028351908,CDM,302,RC,83519,HCPCS,,,facility,both,,,,227,170.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuronal Vgkc Auto Ab (Ref Lab),3028351908,CDM,302,RC,83519,HCPCS,,,facility,both,,,,227,170.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Calcium Channel Ab, N Type (Ref Lab)",3028351909,CDM,302,RC,83519,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Calcium Channel Ab, Q Type (Ref Lab)",3028351910,CDM,302,RC,83519,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vgkc - Complex Ab Ipa, Csf (Ref Lab)",3028351911,CDM,302,RC,83519,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ach Receptor Modulating Ab (Ref Lab),3028351912,CDM,302,RC,83519,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P/Q Type Calcium Channel Ab (Ref Lab),3028351913,CDM,302,RC,83519,HCPCS,,,facility,both,,,,103,77.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P/Q Type Calcium Channel Ab (Ref Lab),3028351913,CDM,302,RC,83519,HCPCS,,,facility,both,,,,103,77.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Musk Autoantibody, S (Ref Lab)",3028351914,CDM,302,RC,83519,HCPCS,,,facility,both,,,,729,546.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Musk Autoantibody, S (Ref Lab)",3028351914,CDM,302,RC,83519,HCPCS,,,facility,both,,,,729,546.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Acetylcholine Rec Mod Ab (Ref Lab),3028351915,CDM,302,RC,83519,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Acetylcholine Rec Mod Ab (Ref Lab),3028351915,CDM,302,RC,83519,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Ria Nonantibody,3028351916,CDM,302,RC,83519,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Ria Nonantibody,3028351917,CDM,302,RC,83519,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Ria Nonantibody,3028351918,CDM,302,RC,83519,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Ria Nonantibody,3028351918,CDM,302,RC,83519,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Mgle Ria Nonantibody,3028351919,CDM,302,RC,83519,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Mgle Ria Nonantibody,3028351920,CDM,302,RC,83519,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Mgle Ria Nonantibody,3028351920,CDM,302,RC,83519,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dys2-Dysautonomia, Autoimmune/Paraneoplastic Evaluation, Serum",3028351921,CDM,302,RC,83519,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dys2-Dysautonomia, Autoimmune/Paraneoplastic Evaluation, Serum",3028351921,CDM,302,RC,83519,HCPCS,,,facility,both,,,,103,77.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Orxna-Orexin-A/Hypocretin-1, Spinal Fluid",3028351922,CDM,302,RC,83519,HCPCS,,,facility,both,,,,1121,840.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Orxna-Orexin-A/Hypocretin-1, Spinal Fluid",3028351922,CDM,302,RC,83519,HCPCS,,,facility,both,,,,1121,840.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Figf2-Insulin-Like Growth Factor 2,3028351923,CDM,302,RC,83519,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Figf2-Insulin-Like Growth Factor 2,3028351923,CDM,302,RC,83519,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Mgmr-Myasthenia Gravis Evaluation With Musk Reflex,3028351924,CDM,302,RC,83519,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Mgmr-Myasthenia Gravis Evaluation With Musk Reflex,3028351924,CDM,302,RC,83519,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Musk-Musk Autoantibody,3028351925,CDM,302,RC,83519,HCPCS,,,facility,both,,,,729,546.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Musk-Musk Autoantibody,3028351925,CDM,302,RC,83519,HCPCS,,,facility,both,,,,729,546.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anti-Mullerian Hormone (Ref Lab),3028352001,CDM,302,RC,83520,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Mullerian Hormone (Ref Lab),3028352001,CDM,302,RC,83520,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Interleukin 2 Receptor (Ref Lab),3028352002,CDM,302,RC,83520,HCPCS,,,facility,both,,,,249,186.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Myeloperoxidase Antibody (Ref Lab),3028352003,CDM,302,RC,83520,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tryptase, Serum (Ref Lab)",3028352004,CDM,302,RC,83520,HCPCS,,,facility,both,,,,227,170.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tryptase, Serum (Ref Lab)",3028352004,CDM,302,RC,83520,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Striated Muscle Antibody (Ref Lab),3028352005,CDM,302,RC,83520,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Striational-Striated Muscle Ab (Ref Lab),3028352006,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thyrotropin Receptor Ab (Ref Lab),3028352007,CDM,302,RC,83520,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thyrotropin Receptor Ab (Ref Lab),3028352007,CDM,302,RC,83520,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Striational Striated Muscle Ab (Ref Lab),3028352008,CDM,302,RC,83520,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunoassay Quant Nos Nonab (Ref Lab),3028352009,CDM,302,RC,83520,HCPCS,,,facility,both,,,,151,113.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phosphatidylethanolamin Ab Iga (Ref Lab),3028352010,CDM,302,RC,83520,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phosphatidylethanolamin Ab Iga (Ref Lab),3028352010,CDM,302,RC,83520,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Phosphatidylethanolamin Ab Igg (Ref Lab),3028352011,CDM,302,RC,83520,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phosphatidylethanolamin Ab Igg (Ref Lab),3028352011,CDM,302,RC,83520,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Phosphatidylethanolamin Ab Igm (Ref Lab),3028352012,CDM,302,RC,83520,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phosphatidylethanolamin Ab Igm (Ref Lab),3028352012,CDM,302,RC,83520,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Insulin Growth Factor Bp-3,Ser (Ref Lab)",3028352013,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Insulin Growth Factor Bp-3,Ser (Ref Lab)",3028352013,CDM,302,RC,83520,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc P1433 Protein, Spinal Fluid (Ref Lab)",3028352014,CDM,302,RC,83520,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rheumatoid Factor Iga (Ref Lab),3028352015,CDM,302,RC,83520,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rheumatoid Factor Iga (Ref Lab),3028352015,CDM,302,RC,83520,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rheumatoid Factor Igg (Ref Lab),3028352016,CDM,302,RC,83520,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rheumatoid Factor Igg (Ref Lab),3028352016,CDM,302,RC,83520,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rheumatoid Factor Igm (Ref Lab),3028352017,CDM,302,RC,83520,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rheumatoid Factor Igm (Ref Lab),3028352017,CDM,302,RC,83520,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc C1 Esterase Inhib, Functional (Ref Lab)",3028352018,CDM,302,RC,83520,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuron-Specific Enolase (Nse) (Ref Lab),3028352019,CDM,302,RC,83520,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuron-Specific Enolase (Nse) (Ref Lab),3028352019,CDM,302,RC,83520,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vasc Endothelial Growth Factor (Ref Lab),3028352020,CDM,302,RC,83520,HCPCS,,,facility,both,,,,228,171,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vasc Endothelial Growth Factor (Ref Lab),3028352020,CDM,302,RC,83520,HCPCS,,,facility,both,,,,229,171.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tumor Necrosis Factor (Ref Lab),3028352021,CDM,302,RC,83520,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tumor Necrosis Factor (Ref Lab),3028352021,CDM,302,RC,83520,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Interleukin 2 (Ref Lab),3028352022,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin 2 Recpt Cd25 Solu (Ref Lab),3028352023,CDM,302,RC,83520,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Interleukin 2 Recpt Cd25 Solu (Ref Lab),3028352023,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin 12 (Ref Lab),3028352024,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interferon Gamma (Ref Lab),3028352025,CDM,302,RC,83520,HCPCS,,,facility,both,,,,182,136.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin 4 (Ref Lab),3028352026,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin 5 (Ref Lab),3028352027,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin 10 (Ref Lab),3028352028,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin 13 (Ref Lab),3028352029,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin (Ref Lab),3028352030,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin 1 Beta (Ref Lab),3028352031,CDM,302,RC,83520,HCPCS,,,facility,both,,,,309,231.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin 6 (Ref Lab),3028352032,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interleukin 8 (Ref Lab),3028352033,CDM,302,RC,83520,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc 14-3-3 Eta Protein (Ref Lab),3028352034,CDM,302,RC,83520,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc 14-3-3 Eta Protein (Ref Lab),3028352034,CDM,302,RC,83520,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Pancreatic Elastase, F (Ref Lab)",3028352035,CDM,302,RC,83520,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pancreatic Elastase, F (Ref Lab)",3028352035,CDM,302,RC,83520,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Il6-Interleukin 6, Plasma",3028352902,CDM,302,RC,83529,HCPCS,,,facility,both,,,,196,147,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Il6-Interleukin 6, Plasma",3028352902,CDM,302,RC,83529,HCPCS,,,facility,both,,,,196,147,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Francisella Tularensis Ab (Ref Lab),3028600001,CDM,302,RC,86000,HCPCS,,,facility,both,,,,159,119.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Candida Albicans Igg (Ref Lab),3028600101,CDM,302,RC,86001,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fhspp-Hypersensitivity Pneumonitis Panel,3028600102,CDM,302,RC,86001,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fhspp-Hypersensitivity Pneumonitis Panel,3028600102,CDM,302,RC,86001,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fhpp2-Hypersensitivity Pneumonitis Feia Panel Ii,3028600103,CDM,302,RC,86001,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fhpp2-Hypersensitivity Pneumonitis Feia Panel Ii,3028600103,CDM,302,RC,86001,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fgfp2-Igg4 Food Panel Ii,3028600104,CDM,302,RC,86001,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fgfp2-Igg4 Food Panel Ii,3028600104,CDM,302,RC,86001,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fg4Fi-Measurement Of Antibody (Igg) To Allergic Substance, Each Allergen",3028600106,CDM,302,RC,86001,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fg4Fi-Measurement Of Antibody (Igg) To Allergic Substance, Each Allergen",3028600106,CDM,302,RC,86001,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600300,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600300,CDM,302,RC,86003,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Allergen Test,Single Allergen (Ref Lab)",3028600301,CDM,302,RC,86003,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Allergen Test,Single Allergen (Ref Lab)",3028600301,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc House Dust Mites/D.P., Ige (Ref Lab)",3028600302,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc House Dust Mites/D.P., Ige (Ref Lab)",3028600302,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc House Dust Mites/D.F., Ige (Ref Lab)",3028600303,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc House Dust Mites/D.F., Ige (Ref Lab)",3028600303,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cat Epithelium, Ige (Ref Lab)",3028600304,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cat Epithelium, Ige (Ref Lab)",3028600304,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Dog Dander, Ige (Ref Lab)",3028600305,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Dog Dander, Ige (Ref Lab)",3028600305,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Timothy Grass, Ige (Ref Lab)",3028600306,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Timothy Grass, Ige (Ref Lab)",3028600306,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cockroach, Ige (Ref Lab)",3028600307,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cockroach, Ige (Ref Lab)",3028600307,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Penicillium, Ige (Ref Lab)",3028600308,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Penicillium, Ige (Ref Lab)",3028600308,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cladosporium, Ige (Ref Lab)",3028600309,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cladosporium, Ige (Ref Lab)",3028600309,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,302860030A,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,302860030A,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,302860030B,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,302860030B,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,302860030C,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,302860030C,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,302860030D,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,302860030D,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030E,CDM,302,RC,86003,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030E,CDM,302,RC,86003,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030F,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030F,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030G,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030G,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030H,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030H,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030I,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030I,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030J,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030J,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030K,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030K,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030L,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030L,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030M,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030M,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030N,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nsip Allg Spec Ige Crude Xtrc Ea,302860030N,CDM,302,RC,86003,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Food6-Food Panel, Serum",302860030O,CDM,302,RC,86003,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Food6-Food Panel, Serum",302860030O,CDM,302,RC,86003,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Immunoglobulin E (Ige), S",302860030P,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Immunoglobulin E (Ige), S",302860030P,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-House Dust Mites/D.P., Ige",302860030Q,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-House Dust Mites/D.P., Ige",302860030Q,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-House Dust Mites/D.F., Ige",302860030R,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-House Dust Mites/D.F., Ige",302860030R,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Cat Epithelium, Ige",302860030S,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Cat Epithelium, Ige",302860030S,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Dog Dander, Ige",302860030T,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Dog Dander, Ige",302860030T,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Bermuda Grass, Ige",302860030U,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Bermuda Grass, Ige",302860030U,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Timothy Grass, Ige",302860030V,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Timothy Grass, Ige",302860030V,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Cockroach, Ige",302860030W,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Cockroach, Ige",302860030W,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Penicillium, Ige",302860030X,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Penicillium, Ige",302860030X,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Cladosporium, Ige",302860030Y,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Cladosporium, Ige",302860030Y,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Aspergillus Fumigatus, Ige",302860030Z,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Aspergillus Fumigatus, Ige",302860030Z,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Aspergillus Fumigatus, Ige (Ref Lab)",3028600310,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Aspergillus Fumigatus, Ige (Ref Lab)",3028600310,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Alternaria Tenuis, Ige (Ref Lab)",3028600311,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Alternaria Tenuis, Ige (Ref Lab)",3028600311,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Box Eld/Maple, S, Ige (Ref Lab)",3028600312,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Box Eld/Maple, S, Ige (Ref Lab)",3028600312,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Grey Alder, Ige (Ref Lab)",3028600313,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Grey Alder, Ige (Ref Lab)",3028600313,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Silver Birch, Ige (Ref Lab)",3028600314,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Silver Birch, Ige (Ref Lab)",3028600314,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mountain Cedar, Ige (Ref Lab)",3028600315,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mountain Cedar, Ige (Ref Lab)",3028600315,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Oak, Ige (Ref Lab)",3028600316,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Oak, Ige (Ref Lab)",3028600316,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Elm, Ige (Ref Lab)",3028600317,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Elm, Ige (Ref Lab)",3028600317,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Walnut Tree, Ige (Ref Lab)",3028600318,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Walnut Tree, Ige (Ref Lab)",3028600318,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cottonwood, Ige (Ref Lab)",3028600319,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cottonwood, Ige (Ref Lab)",3028600319,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc White Ash, Ige (Ref Lab)",3028600320,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc White Ash, Ige (Ref Lab)",3028600320,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Short Ragweed, Ige (Ref Lab)",3028600321,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Short Ragweed, Ige (Ref Lab)",3028600321,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Red Sorrel, Ige (Ref Lab)",3028600322,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Red Sorrel, Ige (Ref Lab)",3028600322,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Nettle, Ige (Ref Lab)",3028600323,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Nettle, Ige (Ref Lab)",3028600323,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Rough Pigweed, Ige (Ref Lab)",3028600324,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rough Pigweed, Ige (Ref Lab)",3028600324,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Food Panel (Ref Lab),3028600325,CDM,302,RC,86003,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Food Panel (Ref Lab),3028600325,CDM,302,RC,86003,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc House Dust/Greer Lab, Ige (Ref Lab)",3028600326,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc House Dust/Greer Lab, Ige (Ref Lab)",3028600326,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc House Dust/H-S Lab, Ige (Ref Lab)",3028600327,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc House Dust/H-S Lab, Ige (Ref Lab)",3028600327,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ascaris, Ige (Ref Lab)",3028600328,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ascaris, Ige (Ref Lab)",3028600328,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bermuda Grass, Ige (Ref Lab)",3028600329,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bermuda Grass, Ige (Ref Lab)",3028600329,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Immunoglobulin E (Ige), S (Ref Lab)",3028600330,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Immunoglobulin E (Ige), S (Ref Lab)",3028600330,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mugwort, Ige (Ref Lab)",3028600331,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mugwort, Ige (Ref Lab)",3028600331,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mulberry, Ige (Ref Lab)",3028600332,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mulberry, Ige (Ref Lab)",3028600332,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Olive-Tree, Ige (Ref Lab)",3028600333,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Olive-Tree, Ige (Ref Lab)",3028600333,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Russian Thistle, Ige (Ref Lab)",3028600334,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Russian Thistle, Ige (Ref Lab)",3028600334,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Peanut, Ige, Serum (Ref Lab)",3028600335,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Peanut, Ige, Serum (Ref Lab)",3028600335,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Egg White, Ige, Serum (Ref Lab)",3028600336,CDM,302,RC,86003,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Egg White, Ige, Serum (Ref Lab)",3028600336,CDM,302,RC,86003,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600337,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600337,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600338,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600338,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600339,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600339,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600340,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600340,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600341,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600341,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600342,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600342,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600343,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600343,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600344,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600344,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600345,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600345,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600346,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600346,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600347,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600347,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600348,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600348,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600349,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600349,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600350,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600350,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600351,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600351,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600352,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600352,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600353,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600353,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600354,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600354,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600355,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600355,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600356,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600356,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600357,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600357,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600358,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600358,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600359,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600359,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600360,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr11 Allg Spec Ige Crude Xtrc Ea,3028600360,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600361,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600361,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600362,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600362,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600363,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600363,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600364,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600364,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600365,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600365,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600366,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600366,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600367,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600367,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600368,CDM,302,RC,86003,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600368,CDM,302,RC,86003,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600369,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600369,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600370,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600370,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600371,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600371,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600372,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600372,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600373,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600373,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600374,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600374,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600375,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600375,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600376,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600376,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600377,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600377,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600378,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600378,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600379,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600379,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600380,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600380,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600381,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr16 Allg Spec Ige Crude Xtrc Ea,3028600381,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600382,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600382,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600383,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600383,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600384,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600384,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600385,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600385,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600386,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600386,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600387,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600387,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600388,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600388,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600389,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600389,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600390,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600390,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600391,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600391,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600392,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600392,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600393,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600393,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600394,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600394,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600395,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600395,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600396,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600396,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600397,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600397,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600398,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600398,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600399,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rpr17 Allg Spec Ige Crude Xtrc Ea,3028600399,CDM,302,RC,86003,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Alternaria Tenuis, Ige",30286003AA,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Alternaria Tenuis, Ige",30286003AA,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Box Eld/Maple, S, Ige",30286003AB,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Box Eld/Maple, S, Ige",30286003AB,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Grey Alder, Ige",30286003AC,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Grey Alder, Ige",30286003AC,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Mountain Cedar, Ige",30286003AD,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Mountain Cedar, Ige",30286003AD,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Oak, Ige",30286003AE,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Oak, Ige",30286003AE,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Elm, Ige",30286003AF,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Elm, Ige",30286003AF,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Olive-Tree, Ige",30286003AG,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Olive-Tree, Ige",30286003AG,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Cottonwood, Ige",30286003AH,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Cottonwood, Ige",30286003AH,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Mulberry, Ige",30286003AI,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Mulberry, Ige",30286003AI,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Short Ragweed, Ige",30286003AJ,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Short Ragweed, Ige",30286003AJ,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Mugwort, Ige",30286003AK,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Mugwort, Ige",30286003AK,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Russian Thistle, Ige",30286003AL,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Russian Thistle, Ige",30286003AL,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Rough Pigweed, Ige",30286003AM,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Rough Pigweed, Ige",30286003AM,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rpr11-Red Sorrel, Ige",30286003AN,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rpr11-Red Sorrel, Ige",30286003AN,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Seafp-Seafood Allergen Profile, Serum",30286003AO,CDM,302,RC,86003,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Seafp-Seafood Allergen Profile, Serum",30286003AO,CDM,302,RC,86003,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dagr-Dairy And Grain Allergen Profile, Serum",30286003AP,CDM,302,RC,86003,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dagr-Dairy And Grain Allergen Profile, Serum",30286003AP,CDM,302,RC,86003,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Nutsp-Nuts Allergen Profile, Serum",30286003AQ,CDM,302,RC,86003,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Nutsp-Nuts Allergen Profile, Serum",30286003AQ,CDM,302,RC,86003,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Seas-Seasonal Inhalants Allergen Profile, Serum",30286003AR,CDM,302,RC,86003,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Seas-Seasonal Inhalants Allergen Profile, Serum",30286003AR,CDM,302,RC,86003,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Mold1-Mold Panel,30286003AW,CDM,302,RC,86003,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Mold1-Mold Panel,30286003AW,CDM,302,RC,86003,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Eggpf-Allergen Specific Ige; Quantitative Or Semiquantitative, Crude Allergen Extract, Ea",30286003AX,CDM,302,RC,86003,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Eggpf-Allergen Specific Ige; Quantitative Or Semiquantitative, Crude Allergen Extract, Ea",30286003AX,CDM,302,RC,86003,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fcurv-Allergen Specific Ige; Quantitative Or Semiquantitative, Crude Allergen Extract, Each",30286003AY,CDM,302,RC,86003,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fcrde-Carmine Dye/Red Dye Cochineal (Dactylopius Coccus) Ige (Red # 4),30286003AZ,CDM,302,RC,86003,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Apgal - Allergen Specific Ige; Quantitative Or Semiquantitative, Crude Allergen Extract, Eac",30286003BA,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Apgal - Allergen Specific Ige; Quantitative Or Semiquantitative, Crude Allergen Extract, Eac",30286003BA,CDM,302,RC,86003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo- Rpr15 Allergen Specific Ige; Quantitative Or Semiquantitative, Crude Allergen Extract, Each",30286003BB,CDM,302,RC,86003,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo- Rpr15 Allergen Specific Ige; Quantitative Or Semiquantitative, Crude Allergen Extract, Each",30286003BB,CDM,302,RC,86003,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fpinp-Allergen Specific Ige; Quantitative Or Semiquantitative, Crude Allergen Extract, Each",30286003BC,CDM,302,RC,86003,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fphas-Phadiatop (Allergy Screen),3028600501,CDM,302,RC,86005,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fphas-Phadiatop (Allergy Screen),3028600501,CDM,302,RC,86005,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Alfa-Alpha-Lactalbumin, Ige, Serum",3028600801,CDM,302,RC,86008,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Alfa-Alpha-Lactalbumin, Ige, Serum",3028600801,CDM,302,RC,86008,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Blac-Beta-Lactoglobulin, Ige, Serum",3028600802,CDM,302,RC,86008,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Blac-Beta-Lactoglobulin, Ige, Serum",3028600802,CDM,302,RC,86008,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Lyso Lysozyme, Ige",3028600803,CDM,302,RC,86008,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Pntcp-Measurement Of Antibody (Ige) To Allergic Substance, Recombinant Or Purified Compon",3028600804,CDM,302,RC,86008,HCPCS,,,facility,both,,,,422,316.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Pntcp-Measurement Of Antibody (Ige) To Allergic Substance, Recombinant Or Purified Compon",3028600804,CDM,302,RC,86008,HCPCS,,,facility,both,,,,367,275.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Eggpf-Allergen Specific Ige; Quantitative Or Semiquantitative, Recombinant Or Purified Co",3028600805,CDM,302,RC,86008,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Eggpf-Allergen Specific Ige; Quantitative Or Semiquantitative, Recombinant Or Purified Co",3028600805,CDM,302,RC,86008,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Algal-Galactose-Alpha-1,3-Galactose, Ige",3028600806,CDM,302,RC,86008,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Apgal - Allergen Specific Ige; Quantitative Or Semiquantitative, Recombinant Or Purified Com",3028600807,CDM,302,RC,86008,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Apgal - Allergen Specific Ige; Quantitative Or Semiquantitative, Recombinant Or Purified Com",3028600807,CDM,302,RC,86008,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Smat-Smooth Muscle Ab Titer, Serum",3028601502,CDM,302,RC,86015,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Smat-Smooth Muscle Ab Titer, Serum",3028601502,CDM,302,RC,86015,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Granulocyte Antibodies (Ref Lab),3028602101,CDM,302,RC,86021,HCPCS,,,facility,both,,,,174,130.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Granulocyte Antibodies (Ref Lab),3028602101,CDM,302,RC,86021,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sra, Unfractionated Heparin (Ref Lab)",3028602201,CDM,302,RC,86022,HCPCS,,,facility,both,,,,443,332.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sra, Unfractionated Heparin (Ref Lab)",3028602201,CDM,302,RC,86022,HCPCS,,,facility,both,,,,443,332.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sra, Unfractionated Heparin Dep Plt Ab (Ref Lab)",3028602202,CDM,302,RC,86022,HCPCS,,,facility,both,,,,465,348.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sra, Unfractionated Heparin Dep Plt Ab (Ref Lab)",3028602202,CDM,302,RC,86022,HCPCS,,,facility,both,,,,464,348,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Heparin-Pf4 Igg Ab (Hit) (Ref Lab),3028602203,CDM,302,RC,86022,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Heparin-Pf4 Igg Ab (Hit) (Ref Lab),3028602203,CDM,302,RC,86022,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Heparin-Pf4 Igg Ab (Hit), S",3028602204,CDM,302,RC,86022,HCPCS,,,facility,both,,,,317,237.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Heparin-Pf4 Igg Ab (Hit), S",3028602204,CDM,302,RC,86022,HCPCS,,,facility,both,,,,231,173.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Heparin-Pf4 Igg Ab (Hit), S",3028602204,CDM,302,RC,86022,HCPCS,,,facility,both,,,,20.21,15.16,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Mayo Anca-Cytoplasmic Neutrophil Antibodies, Serum",3028603602,CDM,302,RC,86036,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Anca-Cytoplasmic Neutrophil Antibodies, Serum",3028603602,CDM,302,RC,86036,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Ibdp2-Antineutrophil Cytoplasmic Antibody (Anca); Screen, Each Antibody",3028603603,CDM,302,RC,86036,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Ibdp2-Antineutrophil Cytoplasmic Antibody (Anca); Screen, Each Antibody",3028603603,CDM,302,RC,86036,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ana/Antinuclear Antibodies (Ref Lab),3028603801,CDM,302,RC,86038,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ana/Antinuclear Antibodies (Ref Lab),3028603801,CDM,302,RC,86038,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anti-Centromere Antibody (Ref Lab),3028603802,CDM,302,RC,86038,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Centromere Antibody (Ref Lab),3028603802,CDM,302,RC,86038,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Antinuclear Ab, S (Ref Lab)",3028603803,CDM,302,RC,86038,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Antinuclear Ab, S (Ref Lab)",3028603803,CDM,302,RC,86038,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ana Antinuclear Antibody,3028603804,CDM,302,RC,86038,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ana Antinuclear Antibody,3028603804,CDM,302,RC,86038,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ana Antinuclear Antibody,3028603804,CDM,302,RC,86038,HCPCS,,,facility,both,,,,14.88,11.16,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Kh Mayo Ctdc Antinuclear Antibodies,3028603805,CDM,302,RC,86038,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Ctdc Antinuclear Antibodies,3028603805,CDM,302,RC,86038,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fscpr-Scleroderma Comp Profile-Screening Test For Autoimmune Disorder,3028603806,CDM,302,RC,86038,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fscpr-Scleroderma Comp Profile-Screening Test For Autoimmune Disorder,3028603806,CDM,302,RC,86038,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Antinuclear Antibody Titer,Ifa (Ref Lab)",3028603901,CDM,302,RC,86039,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Antinuclear Antibody Titer,Ifa (Ref Lab)",3028603901,CDM,302,RC,86039,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mgle-Acetylcholine Receptor Binding Antibody,3028604101,CDM,302,RC,86041,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Mgle-Acetylcholine Receptor Binding Antibody,3028604101,CDM,302,RC,86041,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Mas1-Purkinje Cell Cytoplasmic Ab Type 1,3028605302,CDM,302,RC,86053,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Mas1-Purkinje Cell Cytoplasmic Ab Type 1,3028605302,CDM,302,RC,86053,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Cds1-Cns Demyelinating Disease Eval, S",3028605303,CDM,302,RC,86053,HCPCS,,,facility,both,,,,619,464.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Cds1-Cns Demyelinating Disease Eval, S",3028605303,CDM,302,RC,86053,HCPCS,,,facility,both,,,,619,464.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Pcdes-Aquaporin-4 Antibody Flow Cytometry Each,3028605304,CDM,302,RC,86053,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mac1 - Aquaporin-4 (Neuromyelitis Optica [Nmo]) Antibody; Flow Cytometry (Ie, Fluorescence-A",3028605305,CDM,302,RC,86053,HCPCS,,,facility,both,,,,277,207.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mac1 - Aquaporin-4 (Neuromyelitis Optica [Nmo]) Antibody; Flow Cytometry (Ie, Fluorescence-A",3028605305,CDM,302,RC,86053,HCPCS,,,facility,both,,,,277,207.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Aso/Anti-Streptolysin O (Ref Lab),3028606001,CDM,302,RC,86060,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aso/Anti-Streptolysin O (Ref Lab),3028606001,CDM,302,RC,86060,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sabp Antistreptolysin O Titer,3028606002,CDM,302,RC,86060,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sabp Antistreptolysin O Titer,3028606002,CDM,302,RC,86060,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Crp/C-Reactive Protein,3028614001,CDM,302,RC,86140,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Crp/C-Reactive Protein,3028614001,CDM,302,RC,86140,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Crp/C-Reactive Protein,3028614001,CDM,302,RC,86140,HCPCS,,,facility,both,,,,7.81,5.86,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Crp/C-Reactive Protein,3028614001,CDM,302,RC,86140,HCPCS,,,facility,both,,,,3.52,2.64,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Crp (Outside Ref Lab),3028614002,CDM,302,RC,86140,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Crp (Outside Ref Lab),3028614002,CDM,302,RC,86140,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc High Sensitivity Crp (Ref Lab),3028614101,CDM,302,RC,86141,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc High Sensitivity Crp (Ref Lab),3028614101,CDM,302,RC,86141,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C-Reactive Protein High Sensitivity,3028614102,CDM,302,RC,86141,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C-Reactive Protein High Sensitivity,3028614102,CDM,302,RC,86141,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Crmp1-C-Reactive Protein; High Sensitivity (Hscrp),3028614103,CDM,302,RC,86141,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Beta-2 Glycoprotein 1 Ab, Igg (Ref Lab)",3028614601,CDM,302,RC,86146,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Beta-2 Glycoprotein 1 Ab, Igg (Ref Lab)",3028614601,CDM,302,RC,86146,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Beta-2 Glycoprotein 1 Ab, Igm (Ref Lab)",3028614602,CDM,302,RC,86146,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Beta-2 Glycoprotein 1 Ab, Igm (Ref Lab)",3028614602,CDM,302,RC,86146,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Beta-2 Glycoprotein 1 Ab, Iga (Ref Lab)",3028614603,CDM,302,RC,86146,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Beta-2 Glycoprotein 1 Ab, Iga (Ref Lab)",3028614603,CDM,302,RC,86146,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo B2Gmg Beta-2 Glycoprotein Antibody,3028614604,CDM,302,RC,86146,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo B2Gmg Beta-2 Glycoprotein Antibody,3028614604,CDM,302,RC,86146,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo B2Gmg Beta-2 Glycoprotein Antibody,3028614605,CDM,302,RC,86146,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo B2Gmg Beta-2 Glycoprotein Antibody,3028614605,CDM,302,RC,86146,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phospholipid Ab Igg, S (Ref Lab)",3028614701,CDM,302,RC,86147,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phospholipid Ab Igg, S (Ref Lab)",3028614701,CDM,302,RC,86147,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phospholipid Ab Iga, S (Ref Lab)",3028614702,CDM,302,RC,86147,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phospholipid Ab Iga, S (Ref Lab)",3028614702,CDM,302,RC,86147,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phospholipid Ab Igm, S (Ref Lab)",3028614703,CDM,302,RC,86147,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phospholipid Ab Igm, S (Ref Lab)",3028614703,CDM,302,RC,86147,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Clpmg Cardiolipin Antibody Ea Ig,3028614704,CDM,302,RC,86147,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Clpmg Cardiolipin Antibody Ea Ig,3028614704,CDM,302,RC,86147,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Clpmg Cardiolipin Antibody Ea Ig,3028614705,CDM,302,RC,86147,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Clpmg Cardiolipin Antibody Ea Ig,3028614705,CDM,302,RC,86147,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ps/Pt Ab, Igg, S (Ref Lab)",3028614801,CDM,302,RC,86148,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ps/Pt Ab, Igg, S (Ref Lab)",3028614801,CDM,302,RC,86148,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ps/Pt Ab, Igm, S (Ref Lab)",3028614802,CDM,302,RC,86148,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ps/Pt Ab, Igm, S (Ref Lab)",3028614802,CDM,302,RC,86148,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pspt Anti-Phospholipid Antibody,3028614803,CDM,302,RC,86148,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pspt Anti-Phospholipid Antibody,3028614804,CDM,302,RC,86148,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cold Agglutinin Titer,3028615701,CDM,302,RC,86157,HCPCS,,,facility,both,,,,115,86.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cold Agglutinin Titer,3028615701,CDM,302,RC,86157,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cold Agglutinin Titer,3028615701,CDM,302,RC,86157,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc C-3 Complement Level (Ref Lab),3028616001,CDM,302,RC,86160,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C-3 Complement Level (Ref Lab),3028616001,CDM,302,RC,86160,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C-3 Complement Level (Ref Lab),3028616001,CDM,302,RC,86160,HCPCS,,,facility,both,,,,13.25,9.94,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc C-4 Complement Level (Ref Lab),3028616002,CDM,302,RC,86160,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C-4 Complement Level (Ref Lab),3028616002,CDM,302,RC,86160,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C-4 Complement Level (Ref Lab),3028616002,CDM,302,RC,86160,HCPCS,,,facility,both,,,,13.25,9.94,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Complement Antigen Each Component,3028616003,CDM,302,RC,86160,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Complement Antigen Each Component,3028616003,CDM,302,RC,86160,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  C1Q-Complement C1Q, Serum",3028616004,CDM,302,RC,86160,HCPCS,,,facility,both,,,,140,105,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  C1Q-Complement C1Q, Serum",3028616004,CDM,302,RC,86160,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  C1Q-Complement C1Q, Serum",3028616005,CDM,302,RC,86160,HCPCS,,,facility,both,,,,140,105,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  C1Q-Complement C1Q, Serum",3028616005,CDM,302,RC,86160,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Ahusd- Measurement Of Complement (Immune System Proteins), Antigen,",3028616006,CDM,302,RC,86160,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Ahusd- Measurement Of Complement (Immune System Proteins), Antigen,",3028616006,CDM,302,RC,86160,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fc4Al - Complement; Antigen, Each Component",3028616007,CDM,302,RC,86160,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fc4Al - Complement; Antigen, Each Component",3028616007,CDM,302,RC,86160,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Complement,Alt Path,Function,S (Ref Lab)",3028616101,CDM,302,RC,86161,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ahusd-Measurement Of Complement Function (Immune System Proteins),3028616102,CDM,302,RC,86161,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ahusd-Measurement Of Complement Function (Immune System Proteins),3028616102,CDM,302,RC,86161,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Complement, Total, Serum (Ref Lab)",3028616201,CDM,302,RC,86162,HCPCS,,,facility,both,,,,169,126.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Complement, Total, Serum (Ref Lab)",3028616201,CDM,302,RC,86162,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Ahusd- Measurement Of Complement (Immune System Proteins), Total Hemolytic",3028616203,CDM,302,RC,86162,HCPCS,,,facility,both,,,,334,250.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Ahusd- Measurement Of Complement (Immune System Proteins), Total Hemolytic",3028616203,CDM,302,RC,86162,HCPCS,,,facility,both,,,,334,250.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cyclic Citrullinated Peptd Ab (Ref Lab),3028620001,CDM,302,RC,86200,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyclic Citrullinated Peptd Ab (Ref Lab),3028620001,CDM,302,RC,86200,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cyclic Citrullinated Peptd Ab (Ref Lab),3028620001,CDM,302,RC,86200,HCPCS,,,facility,both,,,,14.63,10.97,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cyclic Citrull Peptide Ab, S (Ref Lab)",3028620002,CDM,302,RC,86200,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Ctdc Ccp Antibody,3028620003,CDM,302,RC,86200,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Ctdc Ccp Antibody,3028620003,CDM,302,RC,86200,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cyclic Citrullinated Peptide Antibody,3028620004,CDM,302,RC,86200,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cyclic Citrullinated Peptide Antibody,3028620004,CDM,302,RC,86200,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Streptococcal Antibodies Profile,3028621501,CDM,302,RC,86215,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Streptococcal Antibodies Profile,3028621501,CDM,302,RC,86215,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anti-Dnase B Titer, Serum (Ref Lab)",3028621502,CDM,302,RC,86215,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Anti-Dnase B Titer, Serum (Ref Lab)",3028621502,CDM,302,RC,86215,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sabp Deoxyribonuclease Antibody,3028621503,CDM,302,RC,86215,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sabp Deoxyribonuclease Antibody,3028621503,CDM,302,RC,86215,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Dna Antibody, Double Strand (Ref Lab)",3028622501,CDM,302,RC,86225,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Dna Antibody, Double Strand (Ref Lab)",3028622501,CDM,302,RC,86225,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Emat-Ema Titer, Serum (Iga)",3028623102,CDM,302,RC,86231,HCPCS,,,facility,both,,,,210,157.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Emat-Ema Titer, Serum (Iga)",3028623102,CDM,302,RC,86231,HCPCS,,,facility,both,,,,210,157.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Emaig-Endomysial Antibody (Ema), Each Immunoglobulin (Ig) Class",3028623103,CDM,302,RC,86231,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ema-Endomysial Antibody Each Immunoglobulin Class,3028623104,CDM,302,RC,86231,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Sclerderma Antibody (Ref Lab),3028623501,CDM,302,RC,86235,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Smith (Sm) Antibody (Ref Lab),3028623502,CDM,302,RC,86235,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Jo-1 Antibody, Igg (Ref Lab)",3028623503,CDM,302,RC,86235,HCPCS,,,facility,both,,,,145,108.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Jo-1 Antibody, Igg (Ref Lab)",3028623503,CDM,302,RC,86235,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rnp Autoantibody (Ref Lab),3028623504,CDM,302,RC,86235,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ssa Antibody, Igg, S (Ref Lab)",3028623505,CDM,302,RC,86235,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ssa Antibody, Igg, S (Ref Lab)",3028623505,CDM,302,RC,86235,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ssb Antibody, Igg, S (Ref Lab)",3028623506,CDM,302,RC,86235,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ssb Antibody, Igg, S (Ref Lab)",3028623506,CDM,302,RC,86235,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sm Ab, Igg, S (Ref Lab)",3028623507,CDM,302,RC,86235,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sm Ab, Igg, S (Ref Lab)",3028623507,CDM,302,RC,86235,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Rnp Ab, Igg, S (Ref Lab)",3028623508,CDM,302,RC,86235,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rnp Ab, Igg, S (Ref Lab)",3028623508,CDM,302,RC,86235,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Scl 70 Ab, Igg, S (Ref Lab)",3028623509,CDM,302,RC,86235,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Scl 70 Ab, Igg, S (Ref Lab)",3028623509,CDM,302,RC,86235,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Jo 1 Ab, Igg, S (Ref Lab)",3028623510,CDM,302,RC,86235,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Jo-1 Ab (Ref Lab),3028623511,CDM,302,RC,86235,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Ssa 52 Kd Gg Ab (Ref Lab),3028623512,CDM,302,RC,86235,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-U1 Rnp Ab (Ref Lab),3028623513,CDM,302,RC,86235,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-U2 Snrnp (Ref Lab),3028623514,CDM,302,RC,86235,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Pm/Scl-100 Ab (Ref Lab),3028623515,CDM,302,RC,86235,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Fibrillarin U3 Rnp Ab (Ref Lab),3028623516,CDM,302,RC,86235,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Mi-2 Ab (Ref Lab),3028623517,CDM,302,RC,86235,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Mi-2 Ab (Ref Lab),3028623517,CDM,302,RC,86235,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ssab Nuclear Antigen Antibody,3028623518,CDM,302,RC,86235,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ssab Nuclear Antigen Antibody,3028623518,CDM,302,RC,86235,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ssab Nuclear Antigen Antibody,3028623519,CDM,302,RC,86235,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ssab Nuclear Antigen Antibody,3028623519,CDM,302,RC,86235,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623520,CDM,302,RC,86235,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623520,CDM,302,RC,86235,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623521,CDM,302,RC,86235,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623521,CDM,302,RC,86235,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623522,CDM,302,RC,86235,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623522,CDM,302,RC,86235,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Enae Nuclear Antigen Antibody,3028623523,CDM,302,RC,86235,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623524,CDM,302,RC,86235,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623524,CDM,302,RC,86235,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623525,CDM,302,RC,86235,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Enae Nuclear Antigen Antibody,3028623525,CDM,302,RC,86235,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Jo-1 Antibody,3028623526,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Jo-1 Antibody,3028623526,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Mi-2 Antibody,3028623527,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Mi-2 Antibody,3028623527,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Pm/Scl-100 Antibody,3028623528,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Pm/Scl-100 Antibody,3028623528,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Ss-A 52Kd Antibody, Igg",3028623529,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-Ss-A 52Kd Antibody, Igg",3028623529,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-U1 Rnp Antibody,3028623530,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-U1 Rnp Antibody,3028623530,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-U2 Rnp Antibody,3028623531,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-U2 Rnp Antibody,3028623531,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-U3 Rnp (Fibrillarin),3028623532,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmmpp (Myomarker 3 Plus Profile)-Anti-U3 Rnp (Fibrillarin),3028623532,CDM,302,RC,86235,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fmmpp-Extractable Nuclear Antigen, Antibody To, Any Method (Eg, Nrnp, Ss-A, Ss-B, Sm, Rn",3028623533,CDM,302,RC,86235,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fmmpp-Extractable Nuclear Antigen, Antibody To, Any Method (Eg, Nrnp, Ss-A, Ss-B, Sm, Rn",3028623533,CDM,302,RC,86235,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fcnab-Chromatin (Nucleosomal) Antibody,3028623534,CDM,302,RC,86235,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fcnab-Chromatin (Nucleosomal) Antibody,3028623534,CDM,302,RC,86235,HCPCS,,,facility,both,,,,144,108,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Ffrft-Extractable Nuclear Antigen Antibody Any Method,3028623536,CDM,302,RC,86235,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Ffrft-Extractable Nuclear Antigen Antibody Any Method,3028623536,CDM,302,RC,86235,HCPCS,,,facility,both,,,,144,108,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fscpr-Scleroderma Comp Profile-Measurement Of Antibody For Assessment Of Autoimmune Disorder,3028623537,CDM,302,RC,86235,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fscpr-Scleroderma Comp Profile-Measurement Of Antibody For Assessment Of Autoimmune Disorder,3028623537,CDM,302,RC,86235,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anti-Endomysial Antibody (Ref Lab),3028625501,CDM,302,RC,86255,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Endomysial Antibody (Ref Lab),3028625501,CDM,302,RC,86255,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anti-Smooth Muscle Antibody (Ref Lab),3028625502,CDM,302,RC,86255,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuromyelitis Optica Aquapor 4 (Ref Lab),3028625503,CDM,302,RC,86255,HCPCS,,,facility,both,,,,987,740.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuromyelitis Optic Serum Aqp4 (Ref Lab),3028625504,CDM,302,RC,86255,HCPCS,,,facility,both,,,,987,740.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuromyelitis Optic Serum Aqp4 (Ref Lab),3028625504,CDM,302,RC,86255,HCPCS,,,facility,both,,,,374,280.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Agn1C (Ref Lab),3028625505,CDM,302,RC,86255,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Agn1C (Ref Lab),3028625505,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Amphc (Ref Lab),3028625506,CDM,302,RC,86255,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amphc (Ref Lab),3028625506,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ann1C (Ref Lab),3028625507,CDM,302,RC,86255,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ann1C (Ref Lab),3028625507,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ann2C (Ref Lab),3028625508,CDM,302,RC,86255,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ann2C (Ref Lab),3028625508,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ann3C (Ref Lab),3028625509,CDM,302,RC,86255,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ann3C (Ref Lab),3028625509,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Mglur1 Ab Ifa, S",302862550A,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Mglur1 Ab Ifa, S",302862550A,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Mog Facs, S",302862550B,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Mog Facs, S",302862550B,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Nif Ifa, S",302862550C,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Nif Ifa, S",302862550C,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Crith-Dna Double-Stranded (Dsdna) Antibodies By Crithidia Luciliae Ifa, Igg, Serum",302862550D,CDM,302,RC,86255,HCPCS,,,facility,both,,,,160,120,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Crith-Dna Double-Stranded (Dsdna) Antibodies By Crithidia Luciliae Ifa, Igg, Serum",302862550D,CDM,302,RC,86255,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Dys2 Purkinje Cell Cytoplasmic Ab Type 2,302862550E,CDM,302,RC,86255,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Dys2 Purkinje Cell Cytoplasmic Ab Type 2,302862550E,CDM,302,RC,86255,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dys2-Anti-Neuronal Nuclear Ab, Type 1",302862550F,CDM,302,RC,86255,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dys2-Anti-Neuronal Nuclear Ab, Type 1",302862550F,CDM,302,RC,86255,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dys2-Caspr2-Igg Cba, S",302862550G,CDM,302,RC,86255,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dys2-Caspr2-Igg Cba, S",302862550G,CDM,302,RC,86255,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dys2-Crmp-5-Igg, S",302862550H,CDM,302,RC,86255,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dys2-Crmp-5-Igg, S",302862550H,CDM,302,RC,86255,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dys2-Dppx Ab Ifa, S",302862550I,CDM,302,RC,86255,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dys2-Dppx Ab Ifa, S",302862550I,CDM,302,RC,86255,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dys2-Lgi1-Igg Cba, S",302862550J,CDM,302,RC,86255,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dys2-Lgi1-Igg Cba, S",302862550J,CDM,302,RC,86255,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ampcs-Ampa-R Ab Cba, Serum",302862550K,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ampcs-Ampa-R Ab Cba, Serum",302862550K,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Amphs-Amphiphysin Ab, Serum",302862550L,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Amphs-Amphiphysin Ab, Serum",302862550L,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dppcs-Dppx Ab Cba, Serum",302862550M,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dppcs-Dppx Ab Cba, Serum",302862550M,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Gabcs-Gaba-B-R Ab Cba, Serum",302862550N,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Gabcs-Gaba-B-R Ab Cba, Serum",302862550N,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Nmdcs-Nmda-R Ab Cba, Serum",302862550O,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Nmdcs-Nmda-R Ab Cba, Serum",302862550O,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Pcabp-Purkinje Cell Cytoplasmic Ab Type 1,302862550P,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Pcabp-Purkinje Cell Cytoplasmic Ab Type 1,302862550P,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Pcatr-Purkinje Cell Cytoplasmic Ab Type Tr,302862550Q,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Pcatr-Purkinje Cell Cytoplasmic Ab Type Tr,302862550Q,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Nf4Fs-Neurofascin-155 Igg4, Flow Cytometry, Serum",302862550R,CDM,302,RC,86255,HCPCS,,,facility,both,,,,557,417.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Nf4Fs-Neurofascin-155 Igg4, Flow Cytometry, Serum",302862550R,CDM,302,RC,86255,HCPCS,,,facility,both,,,,641,480.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Acmfs-Acetylcholine Receptor Modulating Antibody, Flow Cytometry Assay, Serum",302862550S,CDM,302,RC,86255,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Acmfs-Acetylcholine Receptor Modulating Antibody, Flow Cytometry Assay, Serum",302862550S,CDM,302,RC,86255,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Enc2-Crmp-5-Igg Titer,302862550T,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Enc2-Crmp-5-Igg Titer,302862550T,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Ampa-R Antibody Cba, Csf",302862550U,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Ampa-R Antibody Cba, Csf",302862550U,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Amphiphysin Antibody, Csf",302862550V,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Amphiphysin Antibody, Csf",302862550V,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Anti-Glial Nuclear Ab, Type 1",302862550W,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Anti-Glial Nuclear Ab, Type 1",302862550W,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Anti-Neuronal Nuc Ab, Type 1",302862550X,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Anti-Neuronal Nuc Ab, Type 1",302862550X,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Anti-Neuronal Nuc Ab, Type 2",302862550Y,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Anti-Neuronal Nuc Ab, Type 2",302862550Y,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Anti-Neuronal Nuc Ab, Type 3",302862550Z,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Anti-Neuronal Nuc Ab, Type 3",302862550Z,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Crmc (Ref Lab),3028625510,CDM,302,RC,86255,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Crmc (Ref Lab),3028625510,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pca1C (Ref Lab),3028625511,CDM,302,RC,86255,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pca1C (Ref Lab),3028625511,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pca2C (Ref Lab),3028625512,CDM,302,RC,86255,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pca2C (Ref Lab),3028625512,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pctrc (Ref Lab),3028625513,CDM,302,RC,86255,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pctrc (Ref Lab),3028625513,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Nmo/Aqp4 Facs, S (Ref Lab)",3028625514,CDM,302,RC,86255,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Nmo/Aqp4 Facs, S (Ref Lab)",3028625514,CDM,302,RC,86255,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mog Facs, S (Ref Lab)",3028625515,CDM,302,RC,86255,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mog Facs, S (Ref Lab)",3028625515,CDM,302,RC,86255,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Amphiphysin (Ref Lab),3028625516,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amphiphysin (Ref Lab),3028625516,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Crmp-5-Igg (Ref Lab),3028625517,CDM,302,RC,86255,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Crmp-5-Igg (Ref Lab),3028625517,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ampar-Ab (Ref Lab),3028625518,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ampar-Ab (Ref Lab),3028625518,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Nmdar-Ab (Ref Lab),3028625519,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nmdar-Ab (Ref Lab),3028625519,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Nmda-R Ab Cba, Csf (Ref Lab)",3028625520,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Nmda-R Ab Cba, Csf (Ref Lab)",3028625520,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Lgi1-Igg Cba, Csf (Ref Lab)",3028625521,CDM,302,RC,86255,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Caspr2-Igg Cba, Csf (Ref Lab)",3028625522,CDM,302,RC,86255,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gaba-B-R Ab Cba, Csf (Ref Lab)",3028625523,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ampa-R Ab Cba, Csf (Ref Lab)",3028625524,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ampa-R Ab Cba, Csf (Ref Lab)",3028625524,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anti-Neuronal Nuc Ab, Type 1 (Ref Lab)",3028625525,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Anti-Neuronal Nuc Ab, Type 1 (Ref Lab)",3028625525,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anti-Neuronal Nuc Ab, Type 2 (Ref Lab)",3028625526,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Anti-Neuronal Nuc Ab, Type 2 (Ref Lab)",3028625526,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anti-Neuronal Nuc Ab, Type 3 (Ref Lab)",3028625527,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Anti-Neuronal Nuc Ab, Type 3 (Ref Lab)",3028625527,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anti-Glial Nuclear Ab, Type 1 (Ref Lab)",3028625528,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Anti-Glial Nuclear Ab, Type 1 (Ref Lab)",3028625528,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Purkinje Cell Cytopl Ab,Type 2 (Ref Lab)",3028625529,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Purkinje Cell Cytopl Ab,Type 2 (Ref Lab)",3028625529,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Purkinje Cell Cytopl Ab,Typ Tr (Ref Lab)",3028625530,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Purkinje Cell Cytopl Ab,Typ Tr (Ref Lab)",3028625530,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Amphiphysin Ab, Csf (Ref Lab)",3028625531,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Amphiphysin Ab, Csf (Ref Lab)",3028625531,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Crmp-5-Igg, Csf (Ref Lab)",3028625532,CDM,302,RC,86255,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Crmp-5-Igg, Csf (Ref Lab)",3028625532,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Phospholipase A2 Recptr Ifa,S (Ref Lab)",3028625533,CDM,302,RC,86255,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phospholipase A2 Recptr Ifa,S (Ref Lab)",3028625533,CDM,302,RC,86255,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Lgi1-Igg Cba, S (Ref Lab)",3028625534,CDM,302,RC,86255,HCPCS,,,facility,both,,,,329,246.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lgi1-Igg Cba, S (Ref Lab)",3028625534,CDM,302,RC,86255,HCPCS,,,facility,both,,,,329,246.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Caspr2-Igg Cba, S (Ref Lab)",3028625535,CDM,302,RC,86255,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Enceph Autoimmune (Ref Lab),3028625536,CDM,302,RC,86255,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Purkinje Cell Cytopl Ab,Type 1 (Ref Lab)",3028625537,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Purkinje Cell Cytopl Ab,Type 1 (Ref Lab)",3028625537,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mogfs - Mog Facs, S (Ref Lab)",3028625538,CDM,302,RC,86255,HCPCS,,,facility,both,,,,696,522,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mogfs - Mog Facs, S (Ref Lab)",3028625538,CDM,302,RC,86255,HCPCS,,,facility,both,,,,696,522,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cytoplasmic Neutrophil Ab, S (Ref Lab)",3028625539,CDM,302,RC,86255,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cytoplasmic Neutrophil Ab, S (Ref Lab)",3028625539,CDM,302,RC,86255,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Dppx Ab Ifa, S (Ref Lab)",3028625540,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gfap Ifa, S (Ref Lab)",3028625541,CDM,302,RC,86255,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mglur1 Ab Ifa, S (Ref Lab)",3028625542,CDM,302,RC,86255,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gaba-B-R Ab Cba, S (Ref Lab)",3028625543,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mglur1 Ab Cba (Ref Lab),3028625544,CDM,302,RC,86255,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nmo/Aqp4 Facs (Ref Lab),3028625545,CDM,302,RC,86255,HCPCS,,,facility,both,,,,374,280.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nmo/Aqp4 Facs (Ref Lab),3028625545,CDM,302,RC,86255,HCPCS,,,facility,both,,,,373,279.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Phospholipase A2 Recptr Indir (Ref Lab),3028625546,CDM,302,RC,86255,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lgi1 - Igg Cba, S (Ref Lab)",3028625547,CDM,302,RC,86255,HCPCS,,,facility,both,,,,329,246.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Caspr2 - Igg Cba, S (Ref Lab)",3028625548,CDM,302,RC,86255,HCPCS,,,facility,both,,,,329,246.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pla2R Fluorescent Antibody Screen,3028625550,CDM,302,RC,86255,HCPCS,,,facility,both,,,,225,168.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pla2R Fluorescent Antibody Screen,3028625550,CDM,302,RC,86255,HCPCS,,,facility,both,,,,196,147,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625551,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625551,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625552,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625552,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625553,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625553,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625554,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625554,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625555,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625555,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625556,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625556,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625557,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625557,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625558,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625558,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625559,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Paval Fluorescent Antibody Screen,3028625559,CDM,302,RC,86255,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cds1 Fluorescent Antibody Screen,3028625560,CDM,302,RC,86255,HCPCS,,,facility,both,,,,619,464.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cds1 Fluorescent Antibody Screen,3028625560,CDM,302,RC,86255,HCPCS,,,facility,both,,,,538,403.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cds1 Fluorescent Antibody Screen,3028625561,CDM,302,RC,86255,HCPCS,,,facility,both,,,,619,464.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cds1 Fluorescent Antibody Screen,3028625561,CDM,302,RC,86255,HCPCS,,,facility,both,,,,538,403.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625562,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625562,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625563,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625563,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625564,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625564,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625565,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625565,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625566,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625566,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625567,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625567,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625568,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625568,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625569,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625569,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625570,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625570,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625571,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625571,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625572,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625572,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625573,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625573,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625574,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625574,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625575,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625575,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625576,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625576,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625577,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625577,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625578,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625578,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625579,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625579,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625580,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Fluorescent Antibody Screen,3028625580,CDM,302,RC,86255,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625581,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625581,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625582,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625582,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625583,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625583,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625584,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625584,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625585,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625585,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625586,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625586,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625587,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625587,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625588,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625588,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625589,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pac1 Fluorescent Antibody Screen,3028625589,CDM,302,RC,86255,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Glycs-Glycine Receptor Alpha1 Igg, Cell Binding Assay, Serum",3028625590,CDM,302,RC,86255,HCPCS,,,facility,both,,,,727,545.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Glycs-Glycine Receptor Alpha1 Igg, Cell Binding Assay, Serum",3028625590,CDM,302,RC,86255,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Anti-Glial Nuclear Ab, Type 1",3028625591,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Anti-Glial Nuclear Ab, Type 1",3028625591,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Anti-Neuronal Nuclear Ab, Type 1",3028625592,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Anti-Neuronal Nuclear Ab, Type 1",3028625592,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Anti-Neuronal Nuclear Ab, Type 2",3028625593,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Anti-Neuronal Nuclear Ab, Type 2",3028625593,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Anti-Neuronal Nuclear Ab, Type 3",3028625594,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Anti-Neuronal Nuclear Ab, Type 3",3028625594,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Crmp-5-Igg Western Blot, S",3028625595,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Crmp-5-Igg Western Blot, S",3028625595,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Crmp-5-Igg, S",3028625596,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Crmp-5-Igg, S",3028625596,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Dppx Ab Ifa, S",3028625597,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Dppx Ab Ifa, S",3028625597,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Gad65 Ab Assay, S",3028625598,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Gad65 Ab Assay, S",3028625598,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Gfap Ifa, S",3028625599,CDM,302,RC,86255,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Gfap Ifa, S",3028625599,CDM,302,RC,86255,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Caspr2-Igg Cba, Csf",30286255AA,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Caspr2-Igg Cba, Csf",30286255AA,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Enc2-Dppx Ab Ifa,30286255AB,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Enc2-Dppx Ab Ifa,30286255AB,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Gaba-B-R Ab Cba, Csf",30286255AC,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Gaba-B-R Ab Cba, Csf",30286255AC,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Gad65 Ab Assay, Csf",30286255AD,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Gad65 Ab Assay, Csf",30286255AD,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Enc2-Gfap Ifa,30286255AE,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Enc2-Gfap Ifa,30286255AE,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Iglon5 Ifa, Csf",30286255AF,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Iglon5 Ifa, Csf",30286255AF,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Lgi1-Igg Cba, Csf",30286255AG,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Lgi1-Igg Cba, Csf",30286255AG,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Enc2-Mglur1 Ab Ifa,30286255AH,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Enc2-Mglur1 Ab Ifa,30286255AH,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Nif Ifa, Csf",30286255AI,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Nif Ifa, Csf",30286255AI,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Enc2-Nmda-R Ab Cba, Csf",30286255AJ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Enc2-Nmda-R Ab Cba, Csf",30286255AJ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Enc2-Pca1 Csf,30286255AK,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Enc2-Pca1 Csf,30286255AK,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Enc2-Pca2 Csf,30286255AL,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Enc2-Pca2 Csf,30286255AL,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Enc2-Pctr Csf,30286255AM,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Enc2-Pctr Csf,30286255AM,CDM,302,RC,86255,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Acmfs- Achr Modulating Flow Cytometry,30286255AN,CDM,302,RC,86255,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Acmfs- Achr Modulating Flow Cytometry,30286255AN,CDM,302,RC,86255,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Thsd7 Thsd7A Antibody,30286255AO,CDM,306,RC,86255,HCPCS,,,facility,both,,,,506,379.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Thsd7 Thsd7A Antibody,30286255AO,CDM,306,RC,86255,HCPCS,,,facility,both,,,,469,351.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Eps2-Epilepsy, Autoimm/Paraneoplastic, Serum",30286255AQ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,1103,827.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Eps2-Epilepsy, Autoimm/Paraneoplastic, Serum",30286255AQ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,959,719.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dms2-Screening Test For Antibody To Noninfectious Agent,30286255AR,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dms2-Screening Test For Antibody To Noninfectious Agent,30286255AR,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Ig5Is-Fluorescent Nonnfct Agt Antb Screen Ea Antibody,30286255AS,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Ig5Is-Fluorescent Nonnfct Agt Antb Screen Ea Antibody,30286255AS,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Ncdis-Neurocondrin Ifa, Serum",30286255AT,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Ncdis-Neurocondrin Ifa, Serum",30286255AT,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Nifis-Nif Ifa, Serum",30286255AU,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Nifis-Nif Ifa, Serum",30286255AU,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Sp7Is-Septin-7 Ifa, Serum",30286255AV,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Sp7Is-Septin-7 Ifa, Serum",30286255AV,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Ampa-R Ab Cba, Csf",30286255AW,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Ampa-R Ab Cba, Csf",30286255AW,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Amphiphysin Ab, Csf",30286255AX,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Amphiphysin Ab, Csf",30286255AX,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Anti-Glial Nuclear Ab, Type 1",30286255AY,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Anti-Glial Nuclear Ab, Type 1",30286255AY,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Anti-Neuronal Nuclear Ab, Type 1",30286255AZ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Anti-Neuronal Nuclear Ab, Type 1",30286255AZ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Anti-Neuronal Nuclear Ab, Type 2",30286255BA,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Anti-Neuronal Nuclear Ab, Type 2",30286255BA,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Anti-Neuronal Nuclear Ab, Type 3",30286255BB,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Anti-Neuronal Nuclear Ab, Type 3",30286255BB,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Caspr2-Igg Cba, Csf",30286255BC,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Caspr2-Igg Cba, Csf",30286255BC,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Crmp-5-Igg, Csf",30286255BD,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Crmp-5-Igg, Csf",30286255BD,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Dppx Ab Ifa, Csf",30286255BE,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Dppx Ab Ifa, Csf",30286255BE,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Gaba-B-R Ab Cba, Csf",30286255BF,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Gaba-B-R Ab Cba, Csf",30286255BF,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Gfap Ifa, Csf",30286255BG,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Gfap Ifa, Csf",30286255BG,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Lgi1-Igg Cba, Csf",30286255BH,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Lgi1-Igg Cba, Csf",30286255BH,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Mglur1 Ab Ifa, Csf",30286255BI,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Mglur1 Ab Ifa, Csf",30286255BI,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Neurochondrin Ifa, Csf",30286255BJ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Neurochondrin Ifa, Csf",30286255BJ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2-Nmda-R Ab Cba, Csf",30286255BK,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2-Nmda-R Ab Cba, Csf",30286255BK,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Epc2-Purkinje Cell Cytoplasmc Ab Type Tr,30286255BL,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Epc2-Purkinje Cell Cytoplasmc Ab Type Tr,30286255BL,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Epc2-Purkinje Cell Cytoplasmic Ab Type 2,30286255BM,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Epc2-Purkinje Cell Cytoplasmic Ab Type 2,30286255BM,CDM,302,RC,86255,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Aincs-Alpha Internexin, Cell Binding Assay, Serum",30286255BN,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Aincs-Alpha Internexin, Cell Binding Assay, Serum",30286255BN,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Gfacs-Glial Fibrillary Acidic Protein Alpha Subunit Antibody, Cell Binding Assay, Serum",30286255BO,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Gfacs-Glial Fibrillary Acidic Protein Alpha Subunit Antibody, Cell Binding Assay, Serum",30286255BO,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Ig5Cs-Iglon Family Member 5 Antibody, Cell Binding Assay, Serum",30286255BP,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Ig5Cs-Iglon Family Member 5 Antibody, Cell Binding Assay, Serum",30286255BP,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Ncdcs-Neurochondrin Antibody, Cell-Binding Assay, Serum",30286255BQ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Ncdcs-Neurochondrin Antibody, Cell-Binding Assay, Serum",30286255BQ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Nfhcs-Neuronal Intermediate Filament Heavy Chain, Cell Binding Assay, Serum",30286255BR,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Nfhcs-Neuronal Intermediate Filament Heavy Chain, Cell Binding Assay, Serum",30286255BR,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Nflcs-Neuronal Intermediate Filament Light Chain, Cell Binding Assay, Serum",30286255BS,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Nflcs-Neuronal Intermediate Filament Light Chain, Cell Binding Assay, Serum",30286255BS,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Sp7Cs-Septin-7 Antibody, Cell-Binding Assay, Serum",30286255BT,CDM,302,RC,86255,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Sp7Cs-Septin-7 Antibody, Cell-Binding Assay, Serum",30286255BT,CDM,302,RC,86255,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Apbis-Ap3B2 Ifa, Serum",30286255BU,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Apbis-Ap3B2 Ifa, Serum",30286255BU,CDM,302,RC,86255,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Apbis-Ap3B2 Ifa, Serum",30286255BV,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Apbis-Ap3B2 Ifa, Serum",30286255BV,CDM,302,RC,86255,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Nms1-Screening Test For Antibody To Noninfectious Agent,30286255BW,CDM,302,RC,86255,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Nms1-Screening Test For Antibody To Noninfectious Agent,30286255BW,CDM,302,RC,86255,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mds2-Screening Test For Antibody To Noninfectious Agent,30286255BX,CDM,302,RC,86255,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fmgrp-Screening Test For Antibody To Noninfectious Agent,30286255BY,CDM,302,RC,86255,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fmgrp-Screening Test For Antibody To Noninfectious Agent,30286255BY,CDM,302,RC,86255,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fmiga-Screening Test For Antibody To Noninfectious Agent,30286255BZ,CDM,302,RC,86255,HCPCS,,,facility,both,,,,569,426.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Pcdes-Fluorescent Nonnfct Agt Antb Screen Ea Antibody,30286255CA,CDM,302,RC,86255,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mac1 - Fluorescent Noninfectious Agent Antibody; Screen, Each Antibody",30286255CB,CDM,302,RC,86255,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mac1 - Fluorescent Noninfectious Agent Antibody; Screen, Each Antibody",30286255CB,CDM,302,RC,86255,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Zw127-Fluorescent Noninfectious Agent Antibody; Screen, Each Antibody",30286255CD,CDM,302,RC,86255,HCPCS,,,facility,both,,,,1057,792.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Zw127-Fluorescent Noninfectious Agent Antibody; Screen, Each Antibody",30286255CD,CDM,302,RC,86255,HCPCS,,,facility,both,,,,1057,792.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Gid2-Fluorescent Noninfectious Agent Antibody; Screen, Each Antibody",30286255CE,CDM,302,RC,86255,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Gid2-Fluorescent Noninfectious Agent Antibody; Screen, Each Antibody",30286255CE,CDM,302,RC,86255,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anti-Neutrophil Cytopl. Ab (Ref Lab),3028625601,CDM,302,RC,86256,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Neutrophil Cytopl. Ab (Ref Lab),3028625601,CDM,302,RC,86256,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Antineuronal Nuclear Ab,Type1 (Ref Lab)",3028625602,CDM,302,RC,86256,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Antineuronal Nuclear Ab,Type1 (Ref Lab)",3028625602,CDM,302,RC,86256,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Antineuronal Nuclear Ab,Type2 (Ref Lab)",3028625603,CDM,302,RC,86256,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Antineuronal Nuclear Ab,Type2 (Ref Lab)",3028625603,CDM,302,RC,86256,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Antineuronal Nuclear Ab,Type3 (Ref Lab)",3028625604,CDM,302,RC,86256,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Antineuronal Nuclear Ab,Type3 (Ref Lab)",3028625604,CDM,302,RC,86256,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Purkinje Cell Cytopl Ab,Type1 (Ref Lab)",3028625605,CDM,302,RC,86256,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Purkinje Cell Cytopl Ab,Type2 (Ref Lab)",3028625606,CDM,302,RC,86256,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Purkinje Cell Cytopl Ab,Typetr (Ref Lab)",3028625607,CDM,302,RC,86256,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amphiphysin Antibody (Ref Lab),3028625608,CDM,302,RC,86256,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amphiphysin Antibody (Ref Lab),3028625608,CDM,302,RC,86256,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Crmp-5-Igg Titer (Ref Lab),3028625609,CDM,302,RC,86256,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phospholipase A2 Recpt Elisa,S (Ref Lab)",3028625610,CDM,302,RC,86256,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Phospholipase A2 Recpt Elisa,S (Ref Lab)",3028625610,CDM,302,RC,86256,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fovas-Ovarian Ab W/Reflx Titer (Ref Lab),3028625611,CDM,302,RC,86256,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fovas-Ovarian Ab W/Reflx Titer (Ref Lab),3028625611,CDM,302,RC,86256,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fovat - Anti-Ovary Ab Titer (Ref Lab),3028625612,CDM,302,RC,86256,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mog Facs Titer (Ref Lab),3028625613,CDM,302,RC,86256,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mog Facs Titer (Ref Lab),3028625613,CDM,302,RC,86256,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ampis-Ampa-R Ab If Titer Assay, Serum",3028625614,CDM,302,RC,86256,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ampis-Ampa-R Ab If Titer Assay, Serum",3028625614,CDM,302,RC,86256,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dppts-Dppx Ab Ifa Titer, Serum",3028625615,CDM,302,RC,86256,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dppts-Dppx Ab Ifa Titer, Serum",3028625615,CDM,302,RC,86256,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Gabis-Gaba-B-R Ab If Titer Assay, Serum",3028625616,CDM,302,RC,86256,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Gabis-Gaba-B-R Ab If Titer Assay, Serum",3028625616,CDM,302,RC,86256,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Nmdis-Nmda-R Ab If Titer Assay, Serum",3028625617,CDM,302,RC,86256,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Nmdis-Nmda-R Ab If Titer Assay, Serum",3028625617,CDM,302,RC,86256,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Apbts-Ap3B2 Ifa Titer, Serum",3028625619,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Apbts-Ap3B2 Ifa Titer, Serum",3028625619,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Agnts-Ens 2 Reflex: Anti-Glial/Neuronal Nuclear Antibody-Type 1 (Agna-1) Titer, Serum",3028625620,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Agnts-Ens 2 Reflex: Anti-Glial/Neuronal Nuclear Antibody-Type 1 (Agna-1) Titer, Serum",3028625620,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo An1Ts-Antineuronal Nuclear Antibody-Type 1 (Anna-1) Titer, Serum",3028625621,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo An1Ts-Antineuronal Nuclear Antibody-Type 1 (Anna-1) Titer, Serum",3028625621,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo An2Ts-Antineuronal Nuclear Antibody Type 2 (Anna-2) Titer, Serum",3028625622,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo An2Ts-Antineuronal Nuclear Antibody Type 2 (Anna-2) Titer, Serum",3028625622,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo An3Ts-Antineuronal Nuclear Antibody Type 3 (Anna-3) Titer, Serum",3028625623,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo An3Ts-Antineuronal Nuclear Antibody Type 3 (Anna-3) Titer, Serum",3028625623,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Aphts-Amphiphysin Antibody Titer Assay, Serum",3028625624,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Aphts-Amphiphysin Antibody Titer Assay, Serum",3028625624,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Crmts-Collapsin Response-Mediator Protein-5 (Crmp-5) Neuronal Igg Titer, Serum",3028625625,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Crmts-Collapsin Response-Mediator Protein-5 (Crmp-5) Neuronal Igg Titer, Serum",3028625625,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Gfats-Glial Fibrillary Acidic Protein Alpha Subunit Antibody, Immunofluorescence Titer As",3028625626,CDM,302,RC,86256,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Gfats-Glial Fibrillary Acidic Protein Alpha Subunit Antibody, Immunofluorescence Titer As",3028625626,CDM,302,RC,86256,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Gl1Ts-Metabotropic Glutamate Receptor 1 (Mglur1) Antibody By Immunofluorescence Titer Ass,3028625627,CDM,302,RC,86256,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Gl1Ts-Metabotropic Glutamate Receptor 1 (Mglur1) Antibody By Immunofluorescence Titer Ass,3028625627,CDM,302,RC,86256,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Ig5Ts-Iglon Family Member 5 Antibody, Immunofluorescence Titer Assay, Serum",3028625628,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Ig5Ts-Iglon Family Member 5 Antibody, Immunofluorescence Titer Assay, Serum",3028625628,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Ncdts-Neurochondrin Antibody, Tissue Immunofluorescence Titer, Serum",3028625629,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Ncdts-Neurochondrin Antibody, Tissue Immunofluorescence Titer, Serum",3028625629,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Nifts-Neuronal Intermediate Filament Igg, Immunofluorescence Titer Assay, Serum",3028625630,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Nifts-Neuronal Intermediate Filament Igg, Immunofluorescence Titer Assay, Serum",3028625630,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Pc1Ts-Purkinje Cell Cytoplasmic Antibody Type 1 (Pca-1) Titer, Serum",3028625631,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Pc1Ts-Purkinje Cell Cytoplasmic Antibody Type 1 (Pca-1) Titer, Serum",3028625631,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Pc2Ts-Purkinje Cell Cytoplasmic Antibody Type 2 (Pca-2) Titer, Serum",3028625632,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Pc2Ts-Purkinje Cell Cytoplasmic Antibody Type 2 (Pca-2) Titer, Serum",3028625632,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Pctts-Purkinje Cell Cytoplasmic Antibody Type Tr (Pca-Tr) Titer, Serum",3028625633,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Pctts-Purkinje Cell Cytoplasmic Antibody Type Tr (Pca-Tr) Titer, Serum",3028625633,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Sp7Ts-Septin-7 Antibody, Tissue Immunofluorescence Titer, Serum",3028625634,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Sp7Ts-Septin-7 Antibody, Tissue Immunofluorescence Titer, Serum",3028625634,CDM,302,RC,86256,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fscpr-Scleroderma Comp Profile-Measurement Of Antibody To Noninfectious Agent,3028625635,CDM,302,RC,86256,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fscpr-Scleroderma Comp Profile-Measurement Of Antibody To Noninfectious Agent,3028625635,CDM,302,RC,86256,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dagl-Gliadin(Deamidated) Ab, Iga, S",3028625802,CDM,302,RC,86258,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dagl-Gliadin(Deamidated) Ab, Iga, S",3028625802,CDM,302,RC,86258,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dggl-Gliadin(Deamidated) Ab, Igg, S",3028625803,CDM,302,RC,86258,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dggl-Gliadin(Deamidated) Ab, Igg, S",3028625803,CDM,302,RC,86258,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ca 15-3,3028630001,CDM,302,RC,86300,HCPCS,,,facility,both,,,,240,180,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ca 15-3,3028630001,CDM,302,RC,86300,HCPCS,,,facility,both,,,,179,134.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ca 15-3,3028630001,CDM,302,RC,86300,HCPCS,,,facility,both,,,,19.92,14.94,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Ca 15-3,3028630001,CDM,302,RC,86300,HCPCS,,,facility,both,,,,22.89,17.17,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Ca 27-29 (Ref Lab),3028630002,CDM,302,RC,86300,HCPCS,,,facility,both,,,,182,136.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ca 27-29 (Ref Lab),3028630002,CDM,302,RC,86300,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ca 15-3 (Ref Lab),3028630003,CDM,302,RC,86300,HCPCS,,,facility,both,,,,182,136.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ca 15-3 (Ref Lab),3028630003,CDM,302,RC,86300,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ca 19-9 (Ref Lab),3028630101,CDM,302,RC,86301,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ca 19-9 (Ref Lab),3028630101,CDM,302,RC,86301,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ca 19-9 (Ref Lab),3028630101,CDM,302,RC,86301,HCPCS,,,facility,both,,,,22.89,17.17,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Immunoassay Tumor Antigen Quantitative Ca 19-9,3028630102,CDM,302,RC,86301,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunoassay Tumor Antigen Quantitative Ca 19-9,3028630102,CDM,302,RC,86301,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cancer Antigen 125 (Ca-125),3028630401,CDM,302,RC,86304,HCPCS,,,facility,both,,,,223,167.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cancer Antigen 125 (Ca-125),3028630401,CDM,302,RC,86304,HCPCS,,,facility,both,,,,185,138.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cancer Antigen 125 (Ca-125),3028630401,CDM,302,RC,86304,HCPCS,,,facility,both,,,,15.38,11.54,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Cancer Antigen 125 (Ca-125),3028630401,CDM,302,RC,86304,HCPCS,,,facility,both,,,,22.89,17.17,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Human Epididymis Protein 4, Serum (Ref Lab)",3028630501,CDM,302,RC,86305,HCPCS,,,facility,both,,,,261,195.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Human Epididymis Protein 4, Serum (Ref Lab)",3028630501,CDM,302,RC,86305,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mono Test,3028630801,CDM,302,RC,86308,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mono Test,3028630801,CDM,302,RC,86308,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chromogranin A (Ref Lab),3028631601,CDM,302,RC,86316,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chromogranin A (Ref Lab),3028631601,CDM,302,RC,86316,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Phi13-Prostate Health Index Reflex: Pro Psa,3028631602,CDM,302,RC,86316,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Phi13-Prostate Health Index Reflex: Pro Psa,3028631602,CDM,302,RC,86316,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Pneumococcal Ab, Serotype 1 (Ref Lab)",3028631701,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 2 (Ref Lab)",3028631702,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 3 (Ref Lab)",3028631703,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 4 (Ref Lab)",3028631704,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 5 (Ref Lab)",3028631705,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 8 (Ref Lab)",3028631706,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 9N (Ref Lab)",3028631707,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 12F (Ref Lab)",3028631708,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 14 (Ref Lab)",3028631709,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 17F (Ref Lab)",3028631710,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 19F (Ref Lab)",3028631711,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 20 (Ref Lab)",3028631712,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 22F (Ref Lab)",3028631713,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 23F (Ref Lab)",3028631714,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 6B (Ref Lab)",3028631715,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 10A (Ref Lab)",3028631716,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 11A (Ref Lab)",3028631717,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 7F (Ref Lab)",3028631718,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 15B (Ref Lab)",3028631719,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 18C (Ref Lab)",3028631720,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 19A (Ref Lab)",3028631721,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 9V (Ref Lab)",3028631722,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pneumococcal Ab, Serotype 33F (Ref Lab)",3028631723,CDM,302,RC,86317,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Diphtheria Toxoid Igg Ab, S (Ref Lab)",3028631724,CDM,302,RC,86317,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Diphtheria Toxoid Igg Ab, S (Ref Lab)",3028631724,CDM,302,RC,86317,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Tetanus Toxoid Igg Ab, S (Ref Lab)",3028631725,CDM,302,RC,86317,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tetanus Toxoid Igg Ab, S (Ref Lab)",3028631725,CDM,302,RC,86317,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tau Protein (Ref Lab),3028631726,CDM,302,RC,86317,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631727,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631727,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631728,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631728,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631729,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631729,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631730,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631730,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631731,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631731,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631732,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631732,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631733,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631733,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631734,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631734,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631735,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631735,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631736,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631736,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631737,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631737,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631738,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631738,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631739,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631739,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631740,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631740,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631741,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631741,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631742,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631742,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631743,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631743,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631744,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631744,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631745,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631745,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631746,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631746,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631747,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631747,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631748,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pn23 Immunoassay Infectious Agent,3028631748,CDM,302,RC,86317,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Pntor-S. Pneumoniae Igg Ab, With Reflex",3028631749,CDM,302,RC,86317,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Pntor-S. Pneumoniae Igg Ab, With Reflex",3028631749,CDM,302,RC,86317,HCPCS,,,facility,both,,,,248,186,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Arup: Immunoassay For Infectious Agent Antibody, Quantitative, Not Otherwise Specified",3028631751,CDM,302,RC,86317,HCPCS,,,facility,both,,,,775,581.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arup: Immunoassay For Infectious Agent Antibody, Quantitative, Not Otherwise Specified",3028631751,CDM,302,RC,86317,HCPCS,,,facility,both,,,,775,581.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C. Pneumonia Igg (Ref Lab),3028633101,CDM,302,RC,86331,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C. Pneumonia Igg (Ref Lab),3028633101,CDM,302,RC,86331,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C. Pneumonia Iga (Ref Lab),3028633102,CDM,302,RC,86331,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C. Pneumonia Iga (Ref Lab),3028633102,CDM,302,RC,86331,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Immunodiffusion Ouchterlony,3028633103,CDM,302,RC,86331,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Immunodiffusion Ouchterlony,3028633104,CDM,302,RC,86331,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Favi-Hypersensitivity Pneumonitis Avian Panel,3028633105,CDM,302,RC,86331,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Favi-Hypersensitivity Pneumonitis Avian Panel,3028633105,CDM,302,RC,86331,HCPCS,,,facility,both,,,,115,86.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fmypp-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Each Antigen Or Antibod",3028633106,CDM,302,RC,86331,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fmypp-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Each Antigen Or Antibod",3028633106,CDM,302,RC,86331,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Aspergillus Fumigatus #1",3028633107,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Aspergillus Fumigatus #1",3028633107,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Aspergillus Fumigatus #6",3028633108,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Aspergillus Fumigatus #6",3028633108,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Aureobasidium Pullulans",3028633109,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Aureobasidium Pullulans",3028633109,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Pigeon Serum",3028633110,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Pigeon Serum",3028633110,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Micropolyspora Faeni",3028633111,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Micropolyspora Faeni",3028633111,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Thermoactinomyces Vulgar",3028633112,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Thermoactinomyces Vulgar",3028633112,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Aspergillus Flavus",3028633113,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Aspergillus Flavus",3028633113,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Saccharomonospora Viridi",3028633114,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Saccharomonospora Viridi",3028633114,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Thermoactinomyces Candid",3028633115,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Thermoactinomyces Candid",3028633115,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Thermoactinomyces Saccha",3028633116,CDM,302,RC,86331,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fbfpi-Immunodiffusion; Gel Diffusion, Qualitative (Ouchterlony), Thermoactinomyces Saccha",3028633116,CDM,302,RC,86331,HCPCS,,,facility,both,,,,168,126,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C. Pneumonia Igm (Ref Lab),3028633201,CDM,302,RC,86332,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C. Pneumonia Igm (Ref Lab),3028633201,CDM,302,RC,86332,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Immunofixation; Serum (Ref Lab),3028633401,CDM,302,RC,86334,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunofixation Delta & Epsilon (Ref Lab),3028633402,CDM,302,RC,86334,HCPCS,,,facility,both,,,,209,156.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunofixation Delta & Epsilon (Ref Lab),3028633402,CDM,302,RC,86334,HCPCS,,,facility,both,,,,209,156.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Imfxc-Immunofixation Electrophoresis; Serum,3028633404,CDM,302,RC,86334,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Imfxc-Immunofixation Electrophoresis; Serum,3028633404,CDM,302,RC,86334,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fmnpp-Immunofixation Electrophoresis; Serum,3028633405,CDM,302,RC,86334,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fmnpp-Immunofixation Electrophoresis; Serum,3028633405,CDM,302,RC,86334,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Immunofixation; Other Fluid (Ref Lab),3028633501,CDM,302,RC,86335,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunofixation (Ref Lab),3028633502,CDM,302,RC,86335,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Beta-2 Transferrin (Ref Lab),3028633503,CDM,302,RC,86335,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Beta-2 Transferrin (Ref Lab),3028633503,CDM,302,RC,86335,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Immunofixation, Urine (Ref Lab)",3028633504,CDM,302,RC,86335,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Immunofixation, Csf (Ref Lab)",3028633505,CDM,302,RC,86335,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Mpsu Immunfix E-Phorsis/Urine/Csf,3028633506,CDM,302,RC,86335,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Mpsu Immunfix E-Phorsis/Urine/Csf,3028633506,CDM,302,RC,86335,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Rmpsu Immunfix E-Phorsis/Urine/Csf,3028633507,CDM,302,RC,86335,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Rmpsu Immunfix E-Phorsis/Urine/Csf,3028633507,CDM,302,RC,86335,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh  Non Mayo-Immunofixation Electrophoresis; Other Fluids With Concentration (Eg, Urine, Csf)",3028633508,CDM,302,RC,86335,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh  Non Mayo-Immunofixation Electrophoresis; Other Fluids With Concentration (Eg, Urine, Csf)",3028633508,CDM,302,RC,86335,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Insulin Antibodies, Serum (Ref Lab)",3028633701,CDM,302,RC,86337,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Insulin Antibodies, Serum (Ref Lab)",3028633701,CDM,302,RC,86337,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dbs1 Insulin Antibodies,3028633702,CDM,302,RC,86337,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dbs1 Insulin Antibodies,3028633702,CDM,302,RC,86337,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Intrinsic Factor Blocking Ab (Ref Lab),3028634001,CDM,302,RC,86340,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Intrinsic Factor Blocking Ab (Ref Lab),3028634001,CDM,302,RC,86340,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Gad65 (Ref Lab),3028634101,CDM,302,RC,86341,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gad65 Ab Assay, Csf (Ref Lab)",3028634102,CDM,302,RC,86341,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gad65 Ab Assay, Csf (Ref Lab)",3028634102,CDM,302,RC,86341,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Gad65 Antibody Assay, Serum (Ref Lab)",3028634103,CDM,302,RC,86341,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gad65 Antibody Assay, Serum (Ref Lab)",3028634103,CDM,302,RC,86341,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ens2 Islet Cell Antibody,3028634104,CDM,302,RC,86341,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ens2 Islet Cell Antibody,3028634104,CDM,302,RC,86341,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dbs1 Islet Cell Antibody,3028634105,CDM,302,RC,86341,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dbs1 Islet Cell Antibody,3028634105,CDM,302,RC,86341,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dbs1 Islet Cell Antibody,3028634106,CDM,302,RC,86341,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dbs1 Islet Cell Antibody,3028634106,CDM,302,RC,86341,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dbs1 Islet Cell Antibody,3028634107,CDM,302,RC,86341,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dbs1 Islet Cell Antibody,3028634107,CDM,302,RC,86341,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Mas1-Amphiphysin Ab, S",3028634108,CDM,302,RC,86341,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mas1-Amphiphysin Ab, S",3028634108,CDM,302,RC,86341,HCPCS,,,facility,both,,,,243,182.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Enc2-Islet Cell Antibody,3028634109,CDM,302,RC,86341,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Enc2-Islet Cell Antibody,3028634109,CDM,302,RC,86341,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ia2-Islet Antigen 2 (Ia-2) Antibody, Serum",3028634110,CDM,302,RC,86341,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ia2-Islet Antigen 2 (Ia-2) Antibody, Serum",3028634110,CDM,302,RC,86341,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Eznt8-Zinc Transporter 8 (Znt8) Antibody, Serum",3028634111,CDM,302,RC,86341,HCPCS,,,facility,both,,,,800,600,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Eznt8-Zinc Transporter 8 (Znt8) Antibody, Serum",3028634111,CDM,302,RC,86341,HCPCS,,,facility,both,,,,696,522,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Eps2-Islet Cell Antibody,3028634113,CDM,302,RC,86341,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Eps2-Islet Cell Antibody,3028634113,CDM,302,RC,86341,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Dms2-Islet Cell (Pancreas) Antibody Measurement,3028634114,CDM,302,RC,86341,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Dms2-Islet Cell (Pancreas) Antibody Measurement,3028634114,CDM,302,RC,86341,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Epc2- Gad65 Ab Assay, Csf",3028634115,CDM,302,RC,86341,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Epc2- Gad65 Ab Assay, Csf",3028634115,CDM,302,RC,86341,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mds2-Islet Cell Antibody,3028634116,CDM,302,RC,86341,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Pcdes-Islet Cell Antibody,3028634117,CDM,302,RC,86341,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Mac1 - Islet Cell Antibody,3028634118,CDM,302,RC,86341,HCPCS,,,facility,both,,,,174,130.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Mac1 - Islet Cell Antibody,3028634118,CDM,302,RC,86341,HCPCS,,,facility,both,,,,174,130.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fcuip-White Blood Cell Histamine (Immune System Chemical) Release Test,3028634301,CDM,302,RC,86343,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fcuip-White Blood Cell Histamine (Immune System Chemical) Release Test,3028634301,CDM,302,RC,86343,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cell Function Assay W/Stim (Ref Lab),3028635201,CDM,302,RC,86352,HCPCS,,,facility,both,,,,759,569.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cell Function Assay W/Stim (Ref Lab),3028635201,CDM,302,RC,86352,HCPCS,,,facility,both,,,,759,569.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Arup - Cellular Function Assay Involving Stimulation (Eg, Mitogen Or Antigen) And Detection Of Bi",3028635202,CDM,302,RC,86352,HCPCS,,,facility,both,,,,240,180,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arup - Cellular Function Assay Involving Stimulation (Eg, Mitogen Or Antigen) And Detection Of Bi",3028635202,CDM,302,RC,86352,HCPCS,,,facility,both,,,,240,180,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lymphocyte Prolif To Antigens (Ref Lab),3028635301,CDM,302,RC,86353,HCPCS,,,facility,both,,,,378,283.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Mitogens (Ref Lab),3028635302,CDM,302,RC,86353,HCPCS,,,facility,both,,,,378,283.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Add'l Flow Stimulant, Lpmgf (Ref Lab)",3028635303,CDM,302,RC,86353,HCPCS,,,facility,both,,,,347,260.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Transformation (Ref Lab),3028635304,CDM,302,RC,86353,HCPCS,,,facility,both,,,,275,206.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Add'l Flow Stimulant, Lpagf (Ref Lab)",3028635305,CDM,302,RC,86353,HCPCS,,,facility,both,,,,367,275.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Nickel 1 (Ref Lab),3028635306,CDM,302,RC,86353,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Nickel 2 (Ref Lab),3028635307,CDM,302,RC,86353,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Nickel 3 (Ref Lab),3028635308,CDM,302,RC,86353,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Nickel 4 (Ref Lab),3028635309,CDM,302,RC,86353,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Nickel 5 (Ref Lab),3028635310,CDM,302,RC,86353,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Nickel 6 (Ref Lab),3028635311,CDM,302,RC,86353,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Nickel 7 (Ref Lab),3028635312,CDM,302,RC,86353,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Nickel 8 (Ref Lab),3028635313,CDM,302,RC,86353,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lymphocyte Prolif To Nickel 9 (Ref Lab),3028635314,CDM,302,RC,86353,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Cds1-Cns Demyelinating Disease Eval, S",3028635315,CDM,302,RC,86353,HCPCS,,,facility,both,,,,619,464.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Cds1-Cns Demyelinating Disease Eval, S",3028635315,CDM,302,RC,86353,HCPCS,,,facility,both,,,,538,403.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc National Jewish: Lymphocyte Transformation, Mitogen (Phytomitogen) Or Antigen Induced Blastogenes",3028635316,CDM,302,RC,86353,HCPCS,,,facility,both,,,,415,311.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc National Jewish: Lymphocyte Transformation, Mitogen (Phytomitogen) Or Antigen Induced Blastogenes",3028635316,CDM,302,RC,86353,HCPCS,,,facility,both,,,,415,311.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cd8 T Cell Immune Panel(Ref Lab),3028635501,CDM,302,RC,86355,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Qn Lymph Subset : T, B, Nk (Ref Lab)",3028635502,CDM,302,RC,86355,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Tbbs-B Cells Total Count,3028635503,CDM,302,RC,86355,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-Cell Phenotype Antigen 1 (Ref Lab),3028635601,CDM,302,RC,86356,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-Cell Phenotype Antigen 2 (Ref Lab),3028635602,CDM,302,RC,86356,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-Cell Phenotype Antigen 3 (Ref Lab),3028635603,CDM,302,RC,86356,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-Cell Phenotype Antigen 4 (Ref Lab),3028635604,CDM,302,RC,86356,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-Cell Phenotype Antigen 5 (Ref Lab),3028635605,CDM,302,RC,86356,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-Cell Phenotype Antigen 6 (Ref Lab),3028635606,CDM,302,RC,86356,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc B-Cell Phenotype Antigen 7 (Ref Lab),3028635607,CDM,302,RC,86356,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cd20, Total Count (Ref Lab)",3028635608,CDM,302,RC,86356,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mononuclear Cell Antigen (Ref Lab),3028635609,CDM,302,RC,86356,HCPCS,,,facility,both,,,,619,464.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cd4 T-Cell Recent Thymic Emigr (Ref Lab),3028635610,CDM,302,RC,86356,HCPCS,,,facility,both,,,,322,241.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cell Phenotype Advanced Antigen 1 (Ref Lab),3028635611,CDM,302,RC,86356,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cell Phenotype Advanced Antigen 2 (Ref Lab),3028635612,CDM,302,RC,86356,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cell Phenotype Advanced Antigen 3 (Ref Lab),3028635613,CDM,302,RC,86356,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cell Phenotype Advanced Antigen 4 (Ref Lab),3028635614,CDM,302,RC,86356,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cell Phenotype Advanced Antigen 5 (Ref Lab),3028635615,CDM,302,RC,86356,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cell Phenotype Advanced Antigen 6 (Ref Lab),3028635616,CDM,302,RC,86356,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cell Phenotype Advanced Antigen 7 (Ref Lab),3028635617,CDM,302,RC,86356,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cd4Rt-Mononuclear Cell Antigen Quantitative Nos Ea,3028635618,CDM,302,RC,86356,HCPCS,,,facility,both,,,,371,278.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cd4Rt-Mononuclear Cell Antigen Quantitative Nos Ea,3028635618,CDM,302,RC,86356,HCPCS,,,facility,both,,,,323,242.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Tcp-T-Cell Phenotyping, Advanced",3028635619,CDM,302,RC,86356,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Tcp-T-Cell Phenotyping, Advanced",3028635619,CDM,302,RC,86356,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Rbcs-Relative B Cell Subset Analysis %,3028635620,CDM,302,RC,86356,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Rbcs-Relative B Cell Subset Analysis %,3028635620,CDM,302,RC,86356,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Natural Killer Cells (Ref Lab),3028635701,CDM,302,RC,86357,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Tbbs-Natural Killer (Nk) Cells, Total Count",3028635702,CDM,302,RC,86357,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cells Total Count (Ref Lab),3028635901,CDM,302,RC,86359,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cells Total Count (Ref Lab),3028635901,CDM,302,RC,86359,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc T Cells Total Count (Ref Lab),3028635902,CDM,302,RC,86359,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T Cells Total Count (Ref Lab),3028635902,CDM,302,RC,86359,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tcd4 T Cells Total Count,3028635903,CDM,302,RC,86359,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tcd4 T Cells Total Count,3028635903,CDM,302,RC,86359,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Tbbs-T Cells Total Count,3028635904,CDM,302,RC,86359,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Absolute Cd4/Cd8 Count (Ref Lab),3028636001,CDM,302,RC,86360,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tcd4 T Cell Absolute Count/Ratio,3028636002,CDM,302,RC,86360,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tcd4 T Cell Absolute Count/Ratio,3028636002,CDM,302,RC,86360,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Tbbs-T Cells Absolute Cd4&Cd8 Count Ratio,3028636004,CDM,302,RC,86360,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Mas1-Purkinje Cell Cytoplasmic Ab Type 2,3028636302,CDM,302,RC,86363,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Mas1-Purkinje Cell Cytoplasmic Ab Type 2,3028636302,CDM,302,RC,86363,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Mogfs-Mog-Igg1 Antibody Flow Cytometry Each,3028636303,CDM,302,RC,86363,HCPCS,,,facility,both,,,,800,600,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Mogfs-Mog-Igg1 Antibody Flow Cytometry Each,3028636303,CDM,302,RC,86363,HCPCS,,,facility,both,,,,696,522,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Pcdes-Mog-Igg1 Antibody Flow Cytometry Each,3028636304,CDM,302,RC,86363,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ttga-Tissue Transglutaminase Ab, Iga, S",3028636402,CDM,302,RC,86364,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ttga-Tissue Transglutaminase Ab, Iga, S",3028636402,CDM,302,RC,86364,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ttgg-Tissue Transglutaminase Ab, Igg, S",3028636403,CDM,302,RC,86364,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ttgg-Tissue Transglutaminase Ab, Igg, S",3028636403,CDM,302,RC,86364,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Microsomal Ab Liver/Kidney (Ref Lab),3028637601,CDM,302,RC,86376,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Microsomal Ab Liver/Kidney (Ref Lab),3028637601,CDM,302,RC,86376,HCPCS,,,facility,both,,,,104,78,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thyroid Peroxidase Antibody (Ref Lab),3028637602,CDM,302,RC,86376,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thyroid Peroxidase Antibody (Ref Lab),3028637602,CDM,302,RC,86376,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Thyroperoxidase Ab, S (Ref Lab)",3028637603,CDM,302,RC,86376,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Thyroperoxidase Ab, S (Ref Lab)",3028637603,CDM,302,RC,86376,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Thyroid Peroxidase Antibody,3028637604,CDM,302,RC,86376,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Thyroid Peroxidase Antibody,3028637604,CDM,302,RC,86376,HCPCS,,,facility,both,,,,215,161.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thyroid Peroxidase Antibody,3028637604,CDM,302,RC,86376,HCPCS,,,facility,both,,,,144,108,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fcuip-Microsomal Antibodies (Autoantibody) Measurement,3028637606,CDM,302,RC,86376,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fcuip-Microsomal Antibodies (Autoantibody) Measurement,3028637606,CDM,302,RC,86376,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ama-Mitochondrial Antibodies (M2), Serum",3028638102,CDM,302,RC,86381,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ama-Mitochondrial Antibodies (M2), Serum",3028638102,CDM,302,RC,86381,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Polio 1 Titer (Ref Lab),3028638201,CDM,302,RC,86382,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Polio 1 Titer (Ref Lab),3028638201,CDM,302,RC,86382,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Polio 3 Titer (Ref Lab),3028638202,CDM,302,RC,86382,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Polio 3 Titer (Ref Lab),3028638202,CDM,302,RC,86382,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fpolo-Poliovirus (Types 1, 3) Ab, Neut",3028638203,CDM,302,RC,86382,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fpolo-Poliovirus (Types 1, 3) Ab, Neut",3028638203,CDM,302,RC,86382,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fpolo-Poliovirus (Types 1, 3) Ab, Neut",3028638204,CDM,302,RC,86382,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fpolo-Poliovirus (Types 1, 3) Ab, Neut",3028638204,CDM,302,RC,86382,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Frfit- Neutralization Test Viral,3028638205,CDM,302,RC,86382,HCPCS,,,facility,both,,,,218,163.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Frfit- Neutralization Test Viral,3028638205,CDM,302,RC,86382,HCPCS,,,facility,both,,,,273,204.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cryptococcus Antibody (Ref Lab),3028640301,CDM,302,RC,86403,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rheumatoid Factor, Quant",3028643101,CDM,302,RC,86431,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rheumatoid Factor, Quant",3028643101,CDM,302,RC,86431,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Rheumatoid Factor, Quant",3028643101,CDM,302,RC,86431,HCPCS,,,facility,both,,,,9.37,7.03,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Rheumatoid Factor, Quant",3028643101,CDM,302,RC,86431,HCPCS,,,facility,both,,,,8.56,6.42,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Rheumatoid Factor, Quant",3028643101,CDM,302,RC,86431,HCPCS,,,facility,both,,,,3.23,2.42,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Rhut-Rheumatoid Factor, Serum (Ref Lab)",3028643102,CDM,302,RC,86431,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rhut-Rheumatoid Factor, Serum (Ref Lab)",3028643102,CDM,302,RC,86431,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Rapan-Rheumatoid Arthritis Panel, Serum",3028643103,CDM,302,RC,86431,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Rapan-Rheumatoid Arthritis Panel, Serum",3028643103,CDM,302,RC,86431,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Frgam-Rheumatoid Factor Igg,3028643104,CDM,302,RC,86431,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Frgam-Rheumatoid Factor Iga,3028643105,CDM,302,RC,86431,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Frgam-Rheumatoid Factor Igm,3028643106,CDM,302,RC,86431,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Quantiferon-Tb Gold Test (Ref Lab),3028648001,CDM,302,RC,86480,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Quantiferon-Tb Gold Test (Ref Lab),3028648001,CDM,302,RC,86480,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Quantiferon-Tb Gold Plus, B",3028648101,CDM,302,RC,86481,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Quantiferon-Tb Gold Plus, B",3028648101,CDM,302,RC,86481,HCPCS,,,facility,both,,,,396.75,297.56,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Quantiferon-Tb Gold Plus, B",3028648101,CDM,302,RC,86481,HCPCS,,,facility,both,,,,270.25,202.69,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Quantiferon-Tb Gold Plus, B",3028648101,CDM,302,RC,86481,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Tb Intradermal Test Tc,3028658001,CDM,302,RC,86580,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Vdrl, Csf (Ref Lab)",3028659201,CDM,302,RC,86592,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vdrl, Csf (Ref Lab)",3028659201,CDM,302,RC,86592,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Rapid Plasma Reagin, Serum (Ref Lab)",3028659202,CDM,302,RC,86592,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rapid Plasma Reagin, Serum (Ref Lab)",3028659202,CDM,302,RC,86592,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rpr Screen,3028659203,CDM,302,RC,86592,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rpr Screen,3028659203,CDM,302,RC,86592,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rpr Screen,3028659203,CDM,302,RC,86592,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Rpr Titer, S (Ref Lab)",3028659301,CDM,302,RC,86593,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Rpr Titer, S (Ref Lab)",3028659301,CDM,302,RC,86593,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rpr Titer,3028659302,CDM,302,RC,86593,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rpr Titer,3028659302,CDM,302,RC,86593,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Vdsfq-Syphilis Test, Non-Treponemal Antibody; Quantitative",3028659303,CDM,302,RC,86593,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Vdsfq-Syphilis Test, Non-Treponemal Antibody; Quantitative",3028659303,CDM,302,RC,86593,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Voltage Gated Calcium Channel Antibody Each,3028659601,CDM,302,RC,86596,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Mgle- Measurement Of Voltage-Gated Calcium Channel Antibody,3028659602,CDM,302,RC,86596,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Mgle- Measurement Of Voltage-Gated Calcium Channel Antibody,3028659602,CDM,302,RC,86596,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mds2-Measurement Of Voltage-Gated Calcium Channel Antibody,3028659603,CDM,302,RC,86596,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ccpq-Measurement Of Voltage-Gated Calcium Channel Antibody,3028659604,CDM,302,RC,86596,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ccpq-Measurement Of Voltage-Gated Calcium Channel Antibody,3028659604,CDM,302,RC,86596,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Aspergillus Antibody (Ref Lab),3028660601,CDM,302,RC,86606,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspergillus Antibody (Ref Lab),3028660601,CDM,302,RC,86606,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bartonella Henselae, Igg Ab (Ref Lab)",3028661101,CDM,302,RC,86611,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bartonella Henselae, Igg Ab (Ref Lab)",3028661101,CDM,302,RC,86611,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bartonella Henselae, Igm Ab (Ref Lab)",3028661102,CDM,302,RC,86611,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bartonella Henselae, Igm Ab (Ref Lab)",3028661102,CDM,302,RC,86611,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bartonella Quintana Ab, Igg (Ref Lab)",3028661103,CDM,302,RC,86611,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bartonella Quintana Ab, Igg (Ref Lab)",3028661103,CDM,302,RC,86611,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bartonella Quintana Ab, Igm (Ref Lab)",3028661104,CDM,302,RC,86611,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bartonella Quintana Ab, Igm (Ref Lab)",3028661104,CDM,302,RC,86611,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sbl-Blastomyces Ab Immun,Serum (Ref Lab)",3028661201,CDM,302,RC,86612,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sbl-Blastomyces Ab Immun,Serum (Ref Lab)",3028661201,CDM,302,RC,86612,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bordetella Pertussis Ab, Igg (Ref Lab)",3028661501,CDM,302,RC,86615,HCPCS,,,facility,both,,,,115,86.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lyme Ab Igg Immunoblot (Ref Lab),3028661701,CDM,302,RC,86617,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lyme Ab Igg Immunoblot (Ref Lab),3028661701,CDM,302,RC,86617,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lyme Ab Igm Immunoblot (Ref Lab),3028661702,CDM,302,RC,86617,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lyme Ab Igm Immunoblot (Ref Lab),3028661702,CDM,302,RC,86617,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Lywb Lyme Disease Antibody,3028661703,CDM,306,RC,86617,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Lywb Lyme Disease Antibody,3028661704,CDM,302,RC,86617,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Lyme Disease Serology, S (Ref Lab)",3028661801,CDM,302,RC,86618,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lyme Disease Serology, S (Ref Lab)",3028661801,CDM,302,RC,86618,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lyme Cns Infect Igg W/Ai Reflx (Ref Lab),3028661802,CDM,302,RC,86618,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ticks Lyme Disease Antibody,3028661803,CDM,302,RC,86618,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Ticks Lyme Disease Antibody,3028661803,CDM,302,RC,86618,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Stick-Analysis For Antibody Borrelia Burgdorferi (Lyme Disease Bacteria),3028661805,CDM,302,RC,86618,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Stick-Analysis For Antibody Borrelia Burgdorferi (Lyme Disease Bacteria),3028661805,CDM,302,RC,86618,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup - Antibody; Borrelia Burgdorferi (Lyme Disease),3028661806,CDM,302,RC,86618,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup - Antibody; Borrelia Burgdorferi (Lyme Disease),3028661806,CDM,302,RC,86618,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Slyme-Antibody Borrelia Burgdorferi Lyme Disease,3028661807,CDM,302,RC,86618,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Slyme-Antibody Borrelia Burgdorferi Lyme Disease,3028661807,CDM,302,RC,86618,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Brucella Igg Antibody (Ref Lab),3028662201,CDM,302,RC,86622,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Brucella Igg Antibody (Ref Lab),3028662201,CDM,302,RC,86622,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Brucella Igm Antibody (Ref Lab),3028662202,CDM,302,RC,86622,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Brucella Igm Antibody (Ref Lab),3028662202,CDM,302,RC,86622,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Brucella Total Ab, Agglutinatn (Ref Lab)",3028662203,CDM,302,RC,86622,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Brucella Total Ab, Agglutinatn (Ref Lab)",3028662203,CDM,302,RC,86622,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup: Antibody Candida,3028662802,CDM,302,RC,86628,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup: Antibody Candida,3028662802,CDM,302,RC,86628,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chlamydia Igg (Ref Lab),3028663101,CDM,302,RC,86631,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chlamydia Igg (Ref Lab),3028663101,CDM,302,RC,86631,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sclam Chlamydia Antibody,3028663102,CDM,302,RC,86631,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sclam Chlamydia Antibody,3028663102,CDM,302,RC,86631,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sclam Chlamydia Antibody,3028663103,CDM,302,RC,86631,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sclam Chlamydia Antibody,3028663104,CDM,302,RC,86631,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fmpp2-Analysis For Antibody To Chlamydia (Bacteria),3028663105,CDM,302,RC,86631,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fmpp2-Analysis For Antibody To Chlamydia (Bacteria),3028663105,CDM,302,RC,86631,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chlamydia Igm (Ref Lab),3028663201,CDM,302,RC,86632,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chlamydia Igm (Ref Lab),3028663201,CDM,302,RC,86632,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Chlamydia Igm Antibody,3028663202,CDM,302,RC,86632,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sclam Chlamydia Igm Antibody,3028663203,CDM,302,RC,86632,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sclam Chlamydia Igm Antibody,3028663203,CDM,302,RC,86632,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sclam Chlamydia Igm Antibody,3028663204,CDM,302,RC,86632,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sclam Chlamydia Igm Antibody,3028663205,CDM,302,RC,86632,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmypp-Chlamydophila Pneumoniae Ab Igg/A/M,3028663206,CDM,302,RC,86632,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fmypp-Chlamydophila Pneumoniae Ab Igg/A/M,3028663206,CDM,302,RC,86632,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fmpp2-Analysis For Antibody (Igm) To Chlamydia (Bacteria),3028663207,CDM,302,RC,86632,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fmpp2-Analysis For Antibody (Igm) To Chlamydia (Bacteria),3028663207,CDM,302,RC,86632,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cocci Complement F (Ref Lab),3028663501,CDM,302,RC,86635,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cocci Complement F (Ref Lab),3028663501,CDM,302,RC,86635,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cocci Immunodiffusion Igg (Ref Lab),3028663502,CDM,302,RC,86635,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cocci Immunodiffusion Igg (Ref Lab),3028663502,CDM,302,RC,86635,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cocci Immunodiffusion Igm (Ref Lab),3028663503,CDM,302,RC,86635,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cocci Immunodiffusion Igm (Ref Lab),3028663503,CDM,302,RC,86635,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coxis-Coccidioides Ab W/Rflx,S (Ref Lab)",3028663504,CDM,302,RC,86635,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coxis-Coccidioides Ab W/Rflx,S (Ref Lab)",3028663504,CDM,302,RC,86635,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Q Fever Igg Phase I Screen (Ref Lab),3028663801,CDM,302,RC,86638,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Q Fever Igg Phase Ii Screen (Ref Lab),3028663802,CDM,302,RC,86638,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Q Fever Igm Phase I Screen (Ref Lab),3028663803,CDM,302,RC,86638,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Q Fever Igm Phase Ii Screen (Ref Lab),3028663804,CDM,302,RC,86638,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Qfp Q Fever Antibody,3028663805,CDM,302,RC,86638,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Qfp Q Fever Antibody,3028663805,CDM,302,RC,86638,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Qfp Q Fever Antibody,3028663806,CDM,302,RC,86638,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Qfp Q Fever Antibody,3028663806,CDM,302,RC,86638,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Qfp Q Fever Antibody,3028663807,CDM,302,RC,86638,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Qfp Q Fever Antibody,3028663807,CDM,302,RC,86638,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Qfp Q Fever Antibody,3028663808,CDM,302,RC,86638,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Qfp Q Fever Antibody,3028663808,CDM,302,RC,86638,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cmv Screening Per Unit,3028664401,CDM,302,RC,86644,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cmv Screening Per Unit,3028664401,CDM,302,RC,86644,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cytomegalovirus Ab Igg (Ref Lab),3028664402,CDM,302,RC,86644,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cytomegalovirus Ab Igg (Ref Lab),3028664402,CDM,302,RC,86644,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cmv Antibodies, Igg (Ref Lab)",3028664403,CDM,302,RC,86644,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cmv Antibodies, Igg (Ref Lab)",3028664403,CDM,302,RC,86644,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cmvp Cmv Antibody,3028664404,CDM,302,RC,86644,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cmvp Cmv Antibody,3028664404,CDM,302,RC,86644,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Trchg-Antibody; Cytomegalovirus (Cmv),3028664405,CDM,302,RC,86644,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Trchg-Antibody; Cytomegalovirus (Cmv),3028664405,CDM,302,RC,86644,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cytomegalovirus Ab Igm (Ref Lab),3028664501,CDM,302,RC,86645,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cytomegalovirus Ab Igm (Ref Lab),3028664501,CDM,302,RC,86645,HCPCS,,,facility,both,,,,27,20.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cytomegalovirus Ab Igm (Ref Lab),3028664501,CDM,302,RC,86645,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Kh Mayo Cmvp Cmv Antibody Igm,3028664502,CDM,302,RC,86645,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cmvp Cmv Antibody Igm,3028664502,CDM,302,RC,86645,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc California Virus Enceph Ab Igg (Ref Lab),3028665101,CDM,302,RC,86651,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc California Virus Enceph Ab Igm (Ref Lab),3028665102,CDM,302,RC,86651,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Abopc Encephalitis Californ Antbdy,3028665103,CDM,302,RC,86651,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Abopc Encephalitis Californ Antbdy,3028665103,CDM,302,RC,86651,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Abopc Encephalitis Californ Antbdy,3028665104,CDM,302,RC,86651,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Abopc Encephalitis Californ Antbdy,3028665104,CDM,302,RC,86651,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Arbop Encephalitis Californ Antbdy,3028665105,CDM,302,RC,86651,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Arbop Encephalitis Californ Antbdy,3028665105,CDM,302,RC,86651,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Arbop Encephalitis Californ Antbdy,3028665106,CDM,302,RC,86651,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Arbop Encephalitis Californ Antbdy,3028665106,CDM,302,RC,86651,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Eastern Equine Enceph Ab, Igg (Ref Lab)",3028665201,CDM,302,RC,86652,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Eastern Equine Enceph Ab, Igm (Ref Lab)",3028665202,CDM,302,RC,86652,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Abopc Encephaltis East Eqne Anbdy,3028665203,CDM,302,RC,86652,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Abopc Encephaltis East Eqne Anbdy,3028665203,CDM,302,RC,86652,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Abopc Encephaltis East Eqne Anbdy,3028665204,CDM,302,RC,86652,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Abopc Encephaltis East Eqne Anbdy,3028665204,CDM,302,RC,86652,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Arbop Encephaltis East Eqne Anbdy,3028665205,CDM,302,RC,86652,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Arbop Encephaltis East Eqne Anbdy,3028665205,CDM,302,RC,86652,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Arbop Encephaltis East Eqne Anbdy,3028665206,CDM,302,RC,86652,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Arbop Encephaltis East Eqne Anbdy,3028665206,CDM,302,RC,86652,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc St Louis Enceph Ab, Igm, S (Ref Lab)",3028665301,CDM,302,RC,86653,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc St Louis Enceph Ab, Igm, S (Ref Lab)",3028665301,CDM,302,RC,86653,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc St Louis Enceph Ab, Igg, S (Ref Lab)",3028665302,CDM,302,RC,86653,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc St Louis Enceph Ab, Igg, S (Ref Lab)",3028665302,CDM,302,RC,86653,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Abopc Encephaltis St Louis Antbody,3028665303,CDM,302,RC,86653,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Abopc Encephaltis St Louis Antbody,3028665303,CDM,302,RC,86653,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Abopc Encephaltis St Louis Antbody,3028665304,CDM,302,RC,86653,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Abopc Encephaltis St Louis Antbody,3028665304,CDM,302,RC,86653,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Arbop Encephaltis St Louis Antbody,3028665305,CDM,302,RC,86653,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Arbop Encephaltis St Louis Antbody,3028665305,CDM,302,RC,86653,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Arbop Encephaltis St Louis Antbody,3028665306,CDM,302,RC,86653,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Arbop Encephaltis St Louis Antbody,3028665306,CDM,302,RC,86653,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc West Equine Enceph Ab Igm, Csf (Ref Lab)",3028665401,CDM,302,RC,86654,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc West Equine Enceph Ab Igm, Csf (Ref Lab)",3028665401,CDM,302,RC,86654,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc West Equine Enceph Ab Igg, Csf (Ref Lab)",3028665402,CDM,302,RC,86654,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc West Equine Enceph Ab Igg, Csf (Ref Lab)",3028665402,CDM,302,RC,86654,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Weepc Encephaltis West Eqne Antbdy,3028665403,CDM,302,RC,86654,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Weepc Encephaltis West Eqne Antbdy,3028665403,CDM,302,RC,86654,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Abopc Encephaltis West Eqne Antbdy,3028665404,CDM,302,RC,86654,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Abopc Encephaltis West Eqne Antbdy,3028665405,CDM,302,RC,86654,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Abopc Encephaltis West Eqne Antbdy,3028665405,CDM,302,RC,86654,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Arbop Encephaltis West Eqne Antbdy,3028665406,CDM,302,RC,86654,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Arbop Encephaltis West Eqne Antbdy,3028665406,CDM,302,RC,86654,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Arbop Encephaltis West Eqne Antbdy,3028665407,CDM,302,RC,86654,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Arbop Encephaltis West Eqne Antbdy,3028665407,CDM,302,RC,86654,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Weepc Encephaltis West Eqne Antbdy,3028665408,CDM,302,RC,86654,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Weepc Encephaltis West Eqne Antbdy,3028665408,CDM,302,RC,86654,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Coxsackie B1 Ab (Ref Lab),3028665801,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coxsackie B2 Ab (Ref Lab),3028665802,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coxsackie B3 Ab (Ref Lab),3028665803,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coxsackie B4 Ab (Ref Lab),3028665804,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coxsackie B5 Ab (Ref Lab),3028665805,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coxsackie B6 Ab (Ref Lab),3028665806,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echovirus 4 Ab (Ref Lab),3028665807,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echovirus 7 Ab (Ref Lab),3028665808,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echovirus 9 Ab (Ref Lab),3028665809,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echovirus 11 Ab (Ref Lab),3028665810,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echovirus 30 Ab (Ref Lab),3028665811,CDM,302,RC,86658,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665812,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665813,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665814,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665815,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665816,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665817,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665818,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665819,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665820,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665821,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Enterovirus Antibody,3028665822,CDM,302,RC,86658,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmypp-Myocarditis/Pericarditis Panel,3028665823,CDM,302,RC,86658,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fmypp-Myocarditis/Pericarditis Panel,3028665823,CDM,302,RC,86658,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fmpp2-Analysis For Antibody To Enterovirus (Gastrointestinal Virus),3028665824,CDM,302,RC,86658,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fmpp2-Analysis For Antibody To Enterovirus (Gastrointestinal Virus),3028665824,CDM,302,RC,86658,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Epstein-Barr Virus, Early Ag (Ref Lab)",3028666301,CDM,302,RC,86663,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Epstein-Barr Virus, Early Ag (Ref Lab)",3028666301,CDM,302,RC,86663,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Epstein-Barr Ebna Ab, S (Ref Lab)",3028666401,CDM,302,RC,86664,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Epstein-Barr Ebna Ab, S (Ref Lab)",3028666401,CDM,302,RC,86664,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ebv, Epstein-Barr Nuclear Antigen (Ebna) Igg Antibody",3028666402,CDM,302,RC,86664,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ebv, Epstein-Barr Nuclear Antigen (Ebna) Igg Antibody",3028666402,CDM,302,RC,86664,HCPCS,,,facility,both,,,,16.82,12.62,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Ebv, Epstein-Barr Nuclear Antigen (Ebna) Igg Antibody",3028666402,CDM,302,RC,86664,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sebv Epstein-Barr Nuclear Antigen,3028666403,CDM,302,RC,86664,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sebv Epstein-Barr Nuclear Antigen,3028666403,CDM,302,RC,86664,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Epstein-Barr(Ebv) Vca Igm Ab,S (Ref Lab)",3028666501,CDM,302,RC,86665,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Epstein-Barr(Ebv) Vca Igm Ab,S (Ref Lab)",3028666501,CDM,302,RC,86665,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Epstein-Barr(Ebv) Vca Igg Ab,S (Ref Lab)",3028666502,CDM,302,RC,86665,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Epstein-Barr(Ebv) Vca Igg Ab,S (Ref Lab)",3028666502,CDM,302,RC,86665,HCPCS,,,facility,both,,,,14,10.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ebv, Viral Capsid Antigen (Vca) Igg Antibody",3028666503,CDM,302,RC,86665,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ebv, Viral Capsid Antigen (Vca) Igg Antibody",3028666503,CDM,302,RC,86665,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ebv, Viral Capsid Antigen (Vca) Igm Antibody",3028666504,CDM,302,RC,86665,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ebv, Viral Capsid Antigen (Vca) Igm Antibody",3028666504,CDM,302,RC,86665,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sebv Epstein-Barr Capsid Vca,3028666505,CDM,302,RC,86665,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sebv Epstein-Barr Capsid Vca,3028666505,CDM,302,RC,86665,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sebv Epstein-Barr Capsid Vca,3028666506,CDM,302,RC,86665,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sebv Epstein-Barr Capsid Vca,3028666506,CDM,302,RC,86665,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ehrlichia Chaffeensis Ab, Igg",3028666601,CDM,302,RC,86666,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ehrlichia Chaffeensis Ab, Igg",3028666601,CDM,302,RC,86666,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anaplasma Phagocytophl Ab, Igg",3028666602,CDM,302,RC,86666,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Anaplasma Phagocytophl Ab, Igg",3028666602,CDM,302,RC,86666,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ticks Ehrlichia Antibody,3028666603,CDM,302,RC,86666,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Ticks Ehrlichia Antibody,3028666603,CDM,302,RC,86666,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Stick-  Ehrlichia Antibody,3028666604,CDM,302,RC,86666,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Stick-  Ehrlichia Antibody,3028666604,CDM,302,RC,86666,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup - Antibody Ehrlichia,3028666605,CDM,302,RC,86666,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup - Antibody Ehrlichia,3028666605,CDM,302,RC,86666,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Tulab-Francisella Tularensis Antibody, Igm",3028666801,CDM,302,RC,86668,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Tulab-Francisella Tularensis Antibody, Igm",3028666801,CDM,302,RC,86668,HCPCS,,,facility,both,,,,159,119.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Tulab- Igg, Elisa, Serum",3028666802,CDM,302,RC,86668,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Tulab- Igg, Elisa, Serum",3028666802,CDM,302,RC,86668,HCPCS,,,facility,both,,,,159,119.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ibdp2-Analysis For Antibody To Fungus,3028667101,CDM,302,RC,86671,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ibdp2-Analysis For Antibody To Fungus,3028667101,CDM,302,RC,86671,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Strongyloides Antibody, Igg (Ref Lab)",3028668201,CDM,302,RC,86682,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Strongyloides Antibody, Igg (Ref Lab)",3028668201,CDM,302,RC,86682,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cysticercosis Ab, Igg By Elisa (Ref Lab)",3028668202,CDM,302,RC,86682,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cysticercosis Ab, Igg By Elisa (Ref Lab)",3028668202,CDM,302,RC,86682,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Echinococcus Ab, Igg (Ref Lab)",3028668203,CDM,302,RC,86682,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Echinococcus Ab, Igg (Ref Lab)",3028668203,CDM,302,RC,86682,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Schistosoma Species Ab, Igg (Ref Lab)",3028668204,CDM,302,RC,86682,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Schistosoma Species Ab, Igg (Ref Lab)",3028668204,CDM,302,RC,86682,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Toxoc-Toxocara Antibody, Igg, Serum",3028668205,CDM,302,RC,86682,HCPCS,,,facility,both,,,,223,167.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Toxoc-Toxocara Antibody, Igg, Serum",3028668205,CDM,302,RC,86682,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Haemophilus Flu Type B Ab, Igg (Ref Lab)",3028668401,CDM,302,RC,86684,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Haemophilus Flu Type B Ab, Igg (Ref Lab)",3028668401,CDM,302,RC,86684,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Htlv I/Ii  Antibody Confirmation, Serum (Ref Lab)",3028668901,CDM,302,RC,86689,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Htlv I/Ii  Antibody Confirmation, Serum (Ref Lab)",3028668901,CDM,302,RC,86689,HCPCS,,,facility,both,,,,163,122.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hepatitis D Virus Total Antibodies, Serum (Ref Lab)",3028669201,CDM,302,RC,86692,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Herpes Simplex, Type 1, Igg (Ref Lab)",3028669501,CDM,302,RC,86695,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Herpes Simplex, Type 1, Igg (Ref Lab)",3028669501,CDM,302,RC,86695,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Hsvg Herpes Simplex Type 1 Test,3028669502,CDM,302,RC,86695,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hsvg Herpes Simplex Type 1 Test,3028669502,CDM,302,RC,86695,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Trchg-Antibody; Herpes Simplex, Type 1",3028669504,CDM,302,RC,86695,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Trchg-Antibody; Herpes Simplex, Type 1",3028669504,CDM,302,RC,86695,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Herpes Simplex, Type 2, Igg (Ref Lab)",3028669601,CDM,302,RC,86696,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Herpes Simplex, Type 2, Igg (Ref Lab)",3028669601,CDM,302,RC,86696,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Hsvg Herpes Simplex Type 2 Test,3028669602,CDM,302,RC,86696,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hsvg Herpes Simplex Type 2 Test,3028669602,CDM,302,RC,86696,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Trchg-Torch Profile Igg, Serum",3028669604,CDM,302,RC,86696,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Trchg-Torch Profile Igg, Serum",3028669604,CDM,302,RC,86696,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Histoplasma Mycelia Ab (Ref Lab),3028669801,CDM,302,RC,86698,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Histoplasma Mycelia Ab (Ref Lab),3028669801,CDM,302,RC,86698,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histoplasma Yeast Ab (Ref Lab),3028669802,CDM,302,RC,86698,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histoplasma Yeast Ab (Ref Lab),3028669802,CDM,302,RC,86698,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Histoplasma Precipitin Ab (Ref Lab),3028669803,CDM,302,RC,86698,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histoplasma Precipitin Ab (Ref Lab),3028669803,CDM,302,RC,86698,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Shsto Histoplasma Antibody,3028669804,CDM,302,RC,86698,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Shsto Histoplasma Antibody,3028669804,CDM,302,RC,86698,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Shsto Histoplasma Antibody,3028669805,CDM,302,RC,86698,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Shsto Histoplasma Antibody,3028669805,CDM,302,RC,86698,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Shsto Histoplasma Antibody,3028669806,CDM,302,RC,86698,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hiv-1 Antibody (Ref Lab),3028670101,CDM,302,RC,86701,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hvdip Hiv-1Antibody,3028670102,CDM,302,RC,86701,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hvdip Hiv-1Antibody,3028670102,CDM,302,RC,86701,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Hvdip Hiv-1Antibody,3028670102,CDM,302,RC,86701,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Hiv-2 Antibody (Ref Lab),3028670201,CDM,302,RC,86702,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hvdip Hiv-2 Antibody,3028670202,CDM,302,RC,86702,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Hvdip Hiv-2 Antibody,3028670202,CDM,302,RC,86702,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Hvdip Hiv-2 Antibody,3028670202,CDM,302,RC,86702,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Hiv-1/2 Ab, Single Result",3028670301,CDM,302,RC,86703,HCPCS,,,facility,both,,,,172,129,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hiv-1/2 Ab, Single Result",3028670301,CDM,302,RC,86703,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hiv-1/2 Ab, Single Result",3028670301,CDM,302,RC,86703,HCPCS,,,facility,both,,,,15.08,11.31,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Hepatitis B Core Antibody,3028670401,CDM,302,RC,86704,HCPCS,,,facility,both,,,,132,99,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis B Core Antibody,3028670401,CDM,302,RC,86704,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatitis B Core Antibody,3028670401,CDM,302,RC,86704,HCPCS,,,facility,both,,,,12.36,9.27,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Hepatitis B Core Antibody,3028670401,CDM,302,RC,86704,HCPCS,,,facility,both,,,,13.26,9.94,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Hepatitis B-Core Ab, Total (Ref Lab)",3028670402,CDM,302,RC,86704,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hbc Total Ab, W/Reflex, S (Ref Lab)",3028670403,CDM,302,RC,86704,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo  Phsm Hep B Core Antibody Total,3028670404,CDM,302,RC,86704,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo  Phsm Hep B Core Antibody Total,3028670404,CDM,302,RC,86704,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hepatitis B Core Antibody, Igm",3028670501,CDM,302,RC,86705,HCPCS,,,facility,both,,,,12.95,9.71,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Hepatitis B Core Antibody, Igm",3028670501,CDM,302,RC,86705,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hepatitis B Core Antibody, Igm",3028670501,CDM,302,RC,86705,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hepatitis B Core Antibody, Igm",3028670501,CDM,302,RC,86705,HCPCS,,,facility,both,,,,15.64,11.73,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Hepatitis B Core Ab, Igm (Ref Lab)",3028670502,CDM,302,RC,86705,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hep B Surface Antibody,3028670601,CDM,302,RC,86706,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hep B Surface Antibody,3028670601,CDM,302,RC,86706,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hep B Surface Antibody,3028670601,CDM,302,RC,86706,HCPCS,,,facility,both,,,,11.06,8.3,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Hep B Surface Antibody,3028670601,CDM,302,RC,86706,HCPCS,,,facility,both,,,,11.81,8.86,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Hepatitis B Surface Antibody (Ref Lab),3028670602,CDM,302,RC,86706,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo  Phsm Hep B Surface Antibody,3028670603,CDM,302,RC,86706,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo  Phsm Hep B Surface Antibody,3028670603,CDM,302,RC,86706,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatitis Be Antibody (Ref Lab),3028670701,CDM,302,RC,86707,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis Be Antibody (Ref Lab),3028670701,CDM,302,RC,86707,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Chsbp Hepatitis Be Antibody,3028670702,CDM,302,RC,86707,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Chsbp Hepatitis Be Antibody,3028670702,CDM,302,RC,86707,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatitis A Antibody,3028670801,CDM,302,RC,86708,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis A Antibody,3028670801,CDM,302,RC,86708,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatitis A Antibody,3028670801,CDM,302,RC,86708,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Hepatitis A Antibody,3028670801,CDM,302,RC,86708,HCPCS,,,facility,both,,,,13.63,10.22,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Hep A Igg Antibody, Serum (Ref Lab)",3028670802,CDM,302,RC,86708,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hep A Igg Antibody, Serum (Ref Lab)",3028670802,CDM,302,RC,86708,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Previous Hepatitis (Unknown Type), Serum (Ref Lab)",3028670803,CDM,302,RC,86708,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Previous Hepatitis (Unknown Type), Serum (Ref Lab)",3028670803,CDM,302,RC,86708,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo  Phsm Hepatitis A Antibody,3028670804,CDM,302,RC,86708,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo  Phsm Hepatitis A Antibody,3028670804,CDM,302,RC,86708,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hepatitis A Antibody, Igm",3028670901,CDM,302,RC,86709,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hepatitis A Antibody, Igm",3028670901,CDM,302,RC,86709,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hepatitis A Antibody, Igm",3028670901,CDM,302,RC,86709,HCPCS,,,facility,both,,,,14.17,10.63,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Hepatitis A Antibody, Igm",3028670901,CDM,302,RC,86709,HCPCS,,,facility,both,,,,12.39,9.29,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Influenza B Ab, Igg (Ref Lab)",3028671001,CDM,302,RC,86710,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Influenza B Ab, Igm (Ref Lab)",3028671002,CDM,302,RC,86710,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Influenza A Ab (Ref Lab),3028671003,CDM,302,RC,86710,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Influenza B Ab (Ref Lab),3028671004,CDM,302,RC,86710,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fmypp Influenza Virus Antibody,3028671005,CDM,302,RC,86710,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fmypp Influenza Virus Antibody,3028671006,CDM,302,RC,86710,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fmypp-Coxsackie B(1-6) Antibodies, S",3028671007,CDM,302,RC,86710,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fmypp-Coxsackie B(1-6) Antibodies, S",3028671007,CDM,302,RC,86710,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fmypp-Echovirus Antibody Panel, Serum",3028671008,CDM,302,RC,86710,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fmypp-Echovirus Antibody Panel, Serum",3028671008,CDM,302,RC,86710,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fmpp2-Analysis For Antibody To Influenza Virus,3028671009,CDM,302,RC,86710,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fmpp2-Analysis For Antibody To Influenza Virus,3028671009,CDM,302,RC,86710,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Jc Virus Antibody Assay (Ref Lab),3028671101,CDM,302,RC,86711,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Legionella Antibodies (Ref Lab),3028671301,CDM,302,RC,86713,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Legionella Antibodies (Ref Lab),3028671301,CDM,302,RC,86713,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Leptospira, Igm, Serum (Ref Lab)",3028672001,CDM,302,RC,86720,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Leptospira, Igm, Serum (Ref Lab)",3028672001,CDM,302,RC,86720,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mumps Igg - Immunity,3028673501,CDM,302,RC,86735,HCPCS,,,facility,both,,,,71,53.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mumps Igg - Immunity,3028673501,CDM,302,RC,86735,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Mumps Igg - Immunity,3028673501,CDM,302,RC,86735,HCPCS,,,facility,both,,,,14.36,10.77,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Mumps Igg - Immunity,3028673501,CDM,302,RC,86735,HCPCS,,,facility,both,,,,148,111,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mumps Virus Antibody, Igg (Ref Lab)",3028673502,CDM,302,RC,86735,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mumps Virus Antibody, Igg (Ref Lab)",3028673502,CDM,302,RC,86735,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mumps Virus Ab, Igg",3028673503,CDM,302,RC,86735,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mumps Virus Ab, Igg",3028673503,CDM,302,RC,86735,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mumps Virus Ab, Igm",3028673504,CDM,302,RC,86735,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mumps Virus Ab, Igm",3028673504,CDM,302,RC,86735,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cmump-Antibody Mumps,3028673505,CDM,302,RC,86735,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc M. Pneumoniae Ab, Igg, S (Ref Lab)",3028673801,CDM,302,RC,86738,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc M. Pneumoniae Ab, Igg, S (Ref Lab)",3028673801,CDM,302,RC,86738,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc M. Pneumoniae Ab, Igm, S (Ref Lab)",3028673802,CDM,302,RC,86738,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc M. Pneumoniae Ab, Igm, S (Ref Lab)",3028673802,CDM,302,RC,86738,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc M. Pneumoniae Ab, Igm,S By Ifa (Ref Lab)",3028673803,CDM,302,RC,86738,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc M. Pneumoniae Ab, Igm,S By Ifa (Ref Lab)",3028673803,CDM,302,RC,86738,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Myco Mycoplasma Antibody Igm,3028673804,CDM,302,RC,86738,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Myco Mycoplasma Antibody Igm,3028673804,CDM,302,RC,86738,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Myco Mycoplasma Antibody Igg,3028673805,CDM,302,RC,86738,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Myco Mycoplasma Antibody Igg,3028673805,CDM,302,RC,86738,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Parvovirus B19 Antibody, Igg (Ref Lab)",3028674701,CDM,302,RC,86747,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Parvovirus B19 Antibody, Igg (Ref Lab)",3028674701,CDM,302,RC,86747,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Parvovirus B19 Antibody, Igm (Ref Lab)",3028674702,CDM,302,RC,86747,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Parvovirus B19 Antibody, Igm (Ref Lab)",3028674702,CDM,302,RC,86747,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Parvs Parvovirus Antibody,3028674703,CDM,302,RC,86747,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Parvs Parvovirus Antibody,3028674703,CDM,302,RC,86747,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Parvs Parvovirus Antibody,3028674704,CDM,302,RC,86747,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Parvs Parvovirus Antibody,3028674704,CDM,302,RC,86747,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Babesia Microti Ab, Igg (Ref Lab)",3028675301,CDM,302,RC,86753,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Babesia Microti Ab, Igg (Ref Lab)",3028675301,CDM,302,RC,86753,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Entamoeba Histolytica Ab (Ref Lab),3028675302,CDM,302,RC,86753,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Entamoeba Histolytica Ab (Ref Lab),3028675302,CDM,302,RC,86753,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Trypanosoma Cruzi Igg Ab Elisa (Ref Lab),3028675303,CDM,302,RC,86753,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Trypanosoma Cruzi Igg Ab Elisa (Ref Lab),3028675303,CDM,302,RC,86753,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh  Mayo Stick-Antibody; Protozoa, Not Elsewhere Specified",3028675304,CDM,302,RC,86753,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh  Mayo Stick-Antibody; Protozoa, Not Elsewhere Specified",3028675304,CDM,302,RC,86753,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Sam-Entamoeba Histolyica Antibody, Serum",3028675305,CDM,302,RC,86753,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Sam-Entamoeba Histolyica Antibody, Serum",3028675305,CDM,302,RC,86753,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Sam-Entamoeba Histolytica Antibody, Serum",3028675306,CDM,302,RC,86753,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Sam-Entamoeba Histolytica Antibody, Serum",3028675306,CDM,302,RC,86753,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Arup - Antibody; Protozoa, Not Elsewhere Specified",3028675307,CDM,302,RC,86753,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Arup - Antibody; Protozoa, Not Elsewhere Specified",3028675307,CDM,302,RC,86753,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Spotted Fever Group Ab, Igm (Ref Lab)",3028675701,CDM,302,RC,86757,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Spotted Fever Group Ab, Igm (Ref Lab)",3028675701,CDM,302,RC,86757,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Spotted Fever Group Ab, Igg (Ref Lab)",3028675702,CDM,302,RC,86757,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Spotted Fever Group Ab, Igg (Ref Lab)",3028675702,CDM,302,RC,86757,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sfgp Rickettsia Antibody,3028675703,CDM,302,RC,86757,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sfgp Rickettsia Antibody,3028675703,CDM,302,RC,86757,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Sfgp Rickettsia Antibody,3028675704,CDM,302,RC,86757,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Sfgp Rickettsia Antibody,3028675704,CDM,302,RC,86757,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rubella Antibody,3028676201,CDM,302,RC,86762,HCPCS,,,facility,both,,,,15.83,11.87,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Rubella Antibody,3028676201,CDM,302,RC,86762,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rubella Antibody,3028676201,CDM,302,RC,86762,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rubella Antibody,3028676201,CDM,302,RC,86762,HCPCS,,,facility,both,,,,12,9,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Rubella Antibody, Igg (Ref Lab)",3028676202,CDM,302,RC,86762,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rubella Antibody, Igg (Ref Lab)",3028676202,CDM,302,RC,86762,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Trchg-Antibody; Rubella,3028676203,CDM,302,RC,86762,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Trchg-Antibody; Rubella,3028676203,CDM,302,RC,86762,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Measles (Rubeola), Igg",3028676501,CDM,302,RC,86765,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Measles (Rubeola), Igg",3028676501,CDM,302,RC,86765,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Measles (Rubeola), Igg",3028676501,CDM,302,RC,86765,HCPCS,,,facility,both,,,,12.8,9.6,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Measles (Rubeola), Igg",3028676501,CDM,302,RC,86765,HCPCS,,,facility,both,,,,14.17,10.63,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Rubeola, Igg (Ref Lab)",3028676502,CDM,302,RC,86765,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rubeola, Igg (Ref Lab)",3028676502,CDM,302,RC,86765,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Measles (Rubeola) Igm, Ifa (Ref Lab)",3028676503,CDM,302,RC,86765,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Measles (Rubeola) Igm, Ifa (Ref Lab)",3028676503,CDM,302,RC,86765,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Rom-Antibody Rubeola,3028676504,CDM,302,RC,86765,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sars Coronavirus 2 Antibodies,3028676901,CDM,302,RC,86769,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sars Coronavirus 2 Antibodies,3028676901,CDM,302,RC,86769,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Sars Coronavirus 2 Antibodies,3028676901,CDM,302,RC,86769,HCPCS,,,facility,both,,,,46.34,34.76,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Sars Coronavirus 2 Igg Ab, S (Ref Lab)",3028676902,CDM,302,RC,86769,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sars Coronavirus 2 Igg Ab, S (Ref Lab)",3028676902,CDM,302,RC,86769,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Covsq-Sars-Cov-2 Spike Ab, Semi-Quant, Serum",3028676903,CDM,302,RC,86769,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Covsq-Sars-Cov-2 Spike Ab, Semi-Quant, Serum",3028676903,CDM,302,RC,86769,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Toxoplasma Ab, Igg, S (Ref Lab)",3028677701,CDM,302,RC,86777,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Toxoplasma Ab, Igg, S (Ref Lab)",3028677701,CDM,302,RC,86777,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Txmgp Toxoplasma Antibody,3028677702,CDM,302,RC,86777,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Txmgp Toxoplasma Antibody,3028677702,CDM,302,RC,86777,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Trchg-Antibody; Toxoplasma,3028677704,CDM,302,RC,86777,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Trchg-Antibody; Toxoplasma,3028677704,CDM,302,RC,86777,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fggmc-Antibody Toxoplasma,3028677705,CDM,302,RC,86777,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Toxoplasma Ab, Igm, S (Ref Lab)",3028677801,CDM,302,RC,86778,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Toxoplasma Ab, Igm, S (Ref Lab)",3028677801,CDM,302,RC,86778,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Txmgp Toxoplasma Antibody Igm,3028677802,CDM,302,RC,86778,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Txmgp Toxoplasma Antibody Igm,3028677802,CDM,302,RC,86778,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fggmc-Antibody Toxoplasma Igm,3028677804,CDM,302,RC,86778,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Syphilis Igg Antibody,3028678001,CDM,302,RC,86780,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Syphilis Igg Antibody,3028678001,CDM,302,RC,86780,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Syphilis Igg Antibody,3028678001,CDM,302,RC,86780,HCPCS,,,facility,both,,,,13.75,10.31,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Syphilis Igg Antibody,3028678001,CDM,302,RC,86780,HCPCS,,,facility,both,,,,14.56,10.92,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Syphilis Ab, Tp-Pa, S (Ref Lab)",3028678002,CDM,302,RC,86780,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Syphilis Ab, Tp-Pa, S (Ref Lab)",3028678002,CDM,302,RC,86780,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Syphilis Total Ab (Ref Lab),3028678003,CDM,302,RC,86780,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Syphilis Total Ab (Ref Lab),3028678003,CDM,302,RC,86780,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Trichinella Antibody, Serum (Ref Lab)",3028678401,CDM,302,RC,86784,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Trichinella Antibody, Serum (Ref Lab)",3028678401,CDM,302,RC,86784,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Varicella-Zoster Igg- Immunity,3028678701,CDM,302,RC,86787,HCPCS,,,facility,both,,,,132,99,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Varicella-Zoster Igg- Immunity,3028678701,CDM,302,RC,86787,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Varicella-Zoster Igg- Immunity,3028678701,CDM,302,RC,86787,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Varicella-Zoster Igg- Immunity,3028678701,CDM,302,RC,86787,HCPCS,,,facility,both,,,,14.17,10.63,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Varicella Zoster Ab, Igm (Ref Lab)",3028678702,CDM,302,RC,86787,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Varicella Zoster Ab, Igm (Ref Lab)",3028678702,CDM,302,RC,86787,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vzv-Varicella-Zoster Ab (Igg) (Ref Lab),3028678703,CDM,302,RC,86787,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vzv-Varicella-Zoster Ab (Igg) (Ref Lab),3028678703,CDM,302,RC,86787,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Vzv-Varicella-Zoster Ab (Igm) (Ref Lab),3028678704,CDM,302,RC,86787,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vzv-Varicella-Zoster Ab (Igm) (Ref Lab),3028678704,CDM,302,RC,86787,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Varicella Zoster Ab, Igg (Ref Lab)",3028678705,CDM,302,RC,86787,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Varicella Zoster Ab, Igg (Ref Lab)",3028678705,CDM,302,RC,86787,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Varicella-Zoster Ab, Igg, Csf (Ref Lab)",3028678706,CDM,302,RC,86787,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Varicella-Zoster Ab, Igg, Csf (Ref Lab)",3028678706,CDM,302,RC,86787,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Vzgm Varicella-Zoster Antibody,3028678707,CDM,302,RC,86787,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Vzgm Varicella-Zoster Antibody,3028678707,CDM,302,RC,86787,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Vzgm Varicella-Zoster Antibody,3028678708,CDM,302,RC,86787,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Vzgm Varicella-Zoster Antibody,3028678708,CDM,302,RC,86787,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc West Nile Ab, Igm (Ref Lab)",3028678801,CDM,302,RC,86788,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc West Nile Ab, Igm (Ref Lab)",3028678801,CDM,302,RC,86788,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Wnc West Nile Virus Ab Igm,3028678802,CDM,302,RC,86788,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Wnc West Nile Virus Ab Igm,3028678802,CDM,302,RC,86788,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Wns West Nile Virus Ab Igm,3028678803,CDM,302,RC,86788,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Wns West Nile Virus Ab Igm,3028678803,CDM,302,RC,86788,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc West Nile Ab, Igg (Ref Lab)",3028678901,CDM,302,RC,86789,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc West Nile Ab, Igg (Ref Lab)",3028678901,CDM,302,RC,86789,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Wnc West Nile Virus Antibody,3028678902,CDM,302,RC,86789,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Wnc West Nile Virus Antibody,3028678902,CDM,302,RC,86789,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Wns West Nile Virus Antibody,3028678903,CDM,302,RC,86789,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Wns West Nile Virus Antibody,3028678903,CDM,302,RC,86789,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hepatitis E Virus Igm Ab, S (Ref Lab)",3028679001,CDM,302,RC,86790,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Human T-Cell(Htlv I & Ii) Ab,S (Ref Lab)",3028679002,CDM,302,RC,86790,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Human T-Cell(Htlv I & Ii) Ab,S (Ref Lab)",3028679002,CDM,302,RC,86790,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hantavirus Igg Antibody (Ref Lab),3028679003,CDM,302,RC,86790,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hantavirus Igm Antibody (Ref Lab),3028679004,CDM,302,RC,86790,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis E Igm Ab W/Reflex (Ref Lab),3028679005,CDM,302,RC,86790,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis E Virus Igg Ab (Ref Lab),3028679006,CDM,302,RC,86790,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fhvgm Virus Antibody Nos,3028679007,CDM,302,RC,86790,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fhvgm Virus Antibody Nos,3028679007,CDM,302,RC,86790,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fhvgm Virus Antibody Nos,3028679008,CDM,302,RC,86790,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fhvgm Virus Antibody Nos,3028679008,CDM,302,RC,86790,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Fh7Gm-Herpesvirus 7 Igg And Igm Antibody Panel, Ifa",3028679009,CDM,302,RC,86790,HCPCS,,,facility,both,,,,177,132.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Fh7Gm-Herpesvirus 7 Igg And Igm Antibody Panel, Ifa",3028679009,CDM,302,RC,86790,HCPCS,,,facility,both,,,,154,115.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Chikv-Chikungunya Igm And Igg, Ab, Serum",3028679010,CDM,302,RC,86790,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Chikv-Chikungunya Igm And Igg, Ab, Serum",3028679010,CDM,302,RC,86790,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Denvp-Dengue Virus Ab/Ag Panel, S",3028679011,CDM,302,RC,86790,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Denvp-Dengue Virus Ab/Ag Panel, S",3028679011,CDM,302,RC,86790,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw242-Antibody Virus Not Elsewhere Specififed,3028679012,CDM,302,RC,86790,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw242-Antibody Virus Not Elsewhere Specififed,3028679012,CDM,302,RC,86790,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Vzikm-Zika Virus Mac-Elisa, Igm, Serum",3028679401,CDM,302,RC,86794,HCPCS,,,facility,both,,,,262,196.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Vzikm-Zika Virus Mac-Elisa, Igm, Serum",3028679401,CDM,302,RC,86794,HCPCS,,,facility,both,,,,262,196.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anti-Thyroid, Thyroglobulin Ab (Ref Lab)",3028680001,CDM,302,RC,86800,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Anti-Thyroid, Thyroglobulin Ab (Ref Lab)",3028680001,CDM,302,RC,86800,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Thyroglobulin Antibody (Ref Lab),3028680002,CDM,302,RC,86800,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Thyroglobulin Antibody (Ref Lab),3028680002,CDM,302,RC,86800,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tgab-Thyroglb Ab/Thyroglb Rflx (Ref Lab),3028680003,CDM,302,RC,86800,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tgab-Thyroglb Ab/Thyroglb Rflx (Ref Lab),3028680003,CDM,302,RC,86800,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thyroglobulin Antibody,3028680004,CDM,302,RC,86800,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thyroglobulin Antibody,3028680004,CDM,302,RC,86800,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fcuip-Thyroglobulin (Thyroid Protein) Antibody Measurement,3028680005,CDM,302,RC,86800,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fcuip-Thyroglobulin (Thyroid Protein) Antibody Measurement,3028680005,CDM,302,RC,86800,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatitis C Antibody,3028680301,CDM,302,RC,86803,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatitis C Antibody,3028680301,CDM,302,RC,86803,HCPCS,,,facility,both,,,,13.77,10.33,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Hepatitis C Antibody,3028680301,CDM,302,RC,86803,HCPCS,,,facility,both,,,,22.18,16.64,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Hepatitis C Antibody,3028680301,CDM,302,RC,86803,HCPCS,,,facility,both,,,,132,99,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis C Antibody (Ref Lab),3028680302,CDM,302,RC,86803,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis C Antibody (Ref Lab),3028680302,CDM,302,RC,86803,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Phsm Hepatitis C Ab Test,3028680303,CDM,302,RC,86803,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Phsm Hepatitis C Ab Test,3028680303,CDM,302,RC,86803,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hepatitis C Virus Ab Confirm,S (Ref Lab)",3028680401,CDM,302,RC,86804,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hepatitis C Virus Ab Confirm,S (Ref Lab)",3028680401,CDM,302,RC,86804,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hla B-27 (Ref Lab),3028681201,CDM,302,RC,86812,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hla B-27 (Ref Lab),3028681201,CDM,302,RC,86812,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hla Typing, A/B At Inbc",3028681301,CDM,302,RC,86813,HCPCS,,,facility,both,,,,529,396.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hla Typing, A/B At Inbc",3028681301,CDM,302,RC,86813,HCPCS,,,facility,both,,,,460,345,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Non Mayo-Hla Typing-Versiti,3028682801,CDM,302,RC,86828,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Non Mayo-Hla Typing-Versiti,3028682801,CDM,302,RC,86828,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Antibody Screen,3028685001,CDM,302,RC,86850,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Antibody Screen,3028685001,CDM,302,RC,86850,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Antibody Screen,3028685001,CDM,302,RC,86850,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Antibody Screen,3028685001,CDM,302,RC,86850,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Antibody Elution,3028686001,CDM,302,RC,86860,HCPCS,,,facility,both,,,,184,138,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Antibody Elution,3028686001,CDM,302,RC,86860,HCPCS,,,facility,both,,,,184,138,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Antibody Identification,3028687001,CDM,302,RC,86870,HCPCS,,,facility,both,,,,415,311.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Antibody Identification,3028687001,CDM,302,RC,86870,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Antibody Identification,3028687001,CDM,302,RC,86870,HCPCS,,,facility,both,,,,115,86.25,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Coombs Test, Direct",3028688001,CDM,302,RC,86880,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coombs Test, Direct",3028688001,CDM,302,RC,86880,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coombs Test, Direct",3028688001,CDM,302,RC,86880,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Coombs Test, Direct",3028688001,CDM,302,RC,86880,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Inbc Coombs Test, Direct",3028688002,CDM,302,RC,86880,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Inbc Coombs Test, Direct",3028688002,CDM,302,RC,86880,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coombs Test, Indirect",3028688501,CDM,302,RC,86885,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coombs Test, Indirect",3028688501,CDM,302,RC,86885,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Antibody Titer,3028688601,CDM,302,RC,86886,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Antibody Titer,3028688601,CDM,302,RC,86886,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Abo Group, Blood Type",3028690001,CDM,302,RC,86900,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Abo Group, Blood Type",3028690001,CDM,302,RC,86900,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Abo Group, Blood Type",3028690001,CDM,302,RC,86900,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Abo Group, Blood Type",3028690001,CDM,302,RC,86900,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Blood Typing Serologic Abo (Ref Lab),3028690002,CDM,302,RC,86900,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rh Type,3028690101,CDM,302,RC,86901,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rh Type,3028690101,CDM,302,RC,86901,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rh Type,3028690101,CDM,302,RC,86901,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Rh Type,3028690101,CDM,302,RC,86901,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Blood Type Serologic Rh(D) (Ref Lab),3028690102,CDM,302,RC,86901,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Misc Blood Group Antigen, Gp1",3028690501,CDM,302,RC,86905,HCPCS,,,facility,both,,,,370,277.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Misc Blood Group Antigen, Gp1",3028690501,CDM,302,RC,86905,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Misc Blood Group Antigen, Gp2",3028690502,CDM,302,RC,86905,HCPCS,,,facility,both,,,,370,277.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Misc Blood Group Antigen, Gp2",3028690502,CDM,302,RC,86905,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Crossmatch, Blood",3028692001,CDM,302,RC,86920,HCPCS,,,facility,both,,,,252,189,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Compatibility Test, Electronic",3028692301,CDM,302,RC,86923,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Absorption Of Serum For Ab Id,3028697801,CDM,302,RC,86978,HCPCS,,,facility,both,,,,177,132.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hbs Antigen Confirmation, S (Ref Lab)",3028734102,CDM,302,RC,87341,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hbs Antigen Confirmation, S (Ref Lab)",3028734102,CDM,302,RC,87341,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatitis Be Antigen (Ref Lab),3028735001,CDM,302,RC,87350,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis Be Antigen (Ref Lab),3028735001,CDM,302,RC,87350,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Chsbp Hepatitis Be Ag Ia,3028735002,CDM,302,RC,87350,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Chsbp Hepatitis Be Ag Ia,3028735002,CDM,302,RC,87350,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Infectious Agent Antigen Detection By Immunoassay With Direct Optical (Ie, Visual) Observation; S",3028781101,CDM,302,RC,87811,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Infectious Agent Antigen Detection By Immunoassay With Direct Optical (Ie, Visual) Observation; S",3028781101,CDM,302,RC,87811,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Coronavirus, Covid-19 Pcr",302U000201,CDM,302,RC,U0002,HCPCS,,,facility,both,,,,144,108,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coronavirus, Covid-19 Pcr",302U000201,CDM,302,RC,U0002,HCPCS,,,facility,both,,,,144,108,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coronavirus, Covid-19 Pcr",302U000201,CDM,302,RC,U0002,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Sars Coronavirus 2 Rna Detect,302U000301,CDM,302,RC,U0003,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sars Coronavirus 2 Rna Detect,302U000301,CDM,302,RC,U0003,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coronavirus, Sars-Cov2",302U000302,CDM,302,RC,U0003,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coronavirus, Sars-Cov2",302U000302,CDM,302,RC,U0003,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
CRANBERRY JUICE POWDER 425 MG CAPS,30337,CDM,250,RC,43292055812,NDC,,,facility,both,2,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE 60 MG TABS,30487,CDM,250,RC,68084049401,NDC,,,facility,both,2,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE 60 MG TABS,30487,CDM,250,RC,115351101,NDC,,,facility,both,0.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE 60 MG TABS,30487,CDM,250,RC,68084049401,NDC,,,facility,both,1,UN,,10.35,7.76,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE 60 MG TABS,30487,CDM,250,RC,904662261,NDC,,,facility,both,1,UN,,9.75,7.31,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE 60 MG TABS,30487,CDM,250,RC,904662261,NDC,,,facility,both,0.5,UN,,8.65,6.49,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE 60 MG TABS,30487,CDM,250,RC,115351101,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE 60 MG TABS,30487,CDM,250,RC,68084049401,NDC,,,facility,both,0.5,UN,,9,6.75,,,,,,,,,,Gross Charge Type: Pharmacy
QUINAPRIL 20 MG TABS,30534,CDM,250,RC,62135048690,NDC,,,facility,both,0.5,UN,,12.85,9.64,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL 2.5 MG CAPS,30559,CDM,250,RC,68180058901,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL 5 MG CAPS,30560,CDM,250,RC,68382014601,NDC,,,facility,both,4,UN,,2.12,1.59,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL 5 MG CAPS,30560,CDM,250,RC,68382014601,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL 5 MG CAPS,30560,CDM,250,RC,68382014601,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Manual Differential,3058500701,CDM,305,RC,85007,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Manual Differential,3058500701,CDM,305,RC,85007,HCPCS,,,facility,both,,,,24.5,18.38,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Manual Differential,3058500701,CDM,305,RC,85007,HCPCS,,,facility,both,,,,5.18,3.88,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Manual Differential,3058500701,CDM,305,RC,85007,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Microhematocrit, Spun",3058501301,CDM,305,RC,85013,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Microhematocrit, Spun",3058501301,CDM,305,RC,85013,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hematocrit, Automated",3058501401,CDM,305,RC,85014,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hematocrit, Automated",3058501401,CDM,305,RC,85014,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hematocrit, Automated",3058501401,CDM,305,RC,85014,HCPCS,,,facility,both,,,,3.69,2.77,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Hematocrit, Automated",3058501401,CDM,305,RC,85014,HCPCS,,,facility,both,,,,1.87,1.4,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Sacred Heart - Blood Count; Hematocrit (Hct),3058501404,CDM,305,RC,85014,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sacred Heart - Blood Count; Hematocrit (Hct),3058501404,CDM,305,RC,85014,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hemoglobin, Automated Poc",3058501801,CDM,305,RC,85018,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hemoglobin, Automated Poc",3058501801,CDM,305,RC,85018,HCPCS,,,facility,both,,,,3.69,2.77,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Hemoglobin, Automated Poc",3058501801,CDM,305,RC,85018,HCPCS,,,facility,both,,,,2.44,1.83,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Hemoglobin, Automated (Poc)",3058501802,CDM,305,RC,85018,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Hgb, Mixed Venous, Poc",3058501803,CDM,305,RC,85018,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hgb, Venous Bld Gas, Poc",3058501804,CDM,305,RC,85018,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hgb, Mixed Venous, Poc",3058501805,CDM,305,RC,85018,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sacred Heart - Blood Count; Hemoglobin (Hgb),3058501807,CDM,305,RC,85018,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sacred Heart - Blood Count; Hemoglobin (Hgb),3058501807,CDM,305,RC,85018,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cbc,Plt,Automated Diff",3058502501,CDM,305,RC,85025,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Cbc,Plt,Automated Diff",3058502501,CDM,305,RC,85025,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Cbc,Plt,Automated Diff",3058502501,CDM,305,RC,85025,HCPCS,,,facility,both,,,,38.22,28.66,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Cbc,Plt,Automated Diff",3058502501,CDM,305,RC,85025,HCPCS,,,facility,both,,,,9.07,6.8,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cbc,Plt,Automated Diff",3058502501,CDM,305,RC,85025,HCPCS,,,facility,both,,,,1.68,1.26,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Cbc,Plt,Manual Diff",3058502701,CDM,305,RC,85027,HCPCS,,,facility,both,,,,8.33,6.25,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Cbc,Plt,Manual Diff",3058502701,CDM,305,RC,85027,HCPCS,,,facility,both,,,,1.68,1.26,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Cbc,Plt,Manual Diff",3058502701,CDM,305,RC,85027,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cbc,Plt,Manual Diff",3058502701,CDM,305,RC,85027,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hemogram & Plt, Automated",3058502702,CDM,305,RC,85027,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hemogram & Plt, Automated",3058502702,CDM,305,RC,85027,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hemogram & Plt, Automated",3058502702,CDM,305,RC,85027,HCPCS,,,facility,both,,,,8.58,6.44,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Hemogram & Plt, Automated",3058502702,CDM,305,RC,85027,HCPCS,,,facility,both,,,,1.68,1.26,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Rbc Red Blood Cell Count,3058504101,CDM,305,RC,85041,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rbc Red Blood Cell Count,3058504101,CDM,305,RC,85041,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Reticulocyte Count,3058504501,CDM,305,RC,85045,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Reticulocyte Count,3058504601,CDM,305,RC,85046,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Reticulocyte Count,3058504601,CDM,305,RC,85046,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Reticulocyte Count,3058504601,CDM,305,RC,85046,HCPCS,,,facility,both,,,,8.4,6.3,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Reticulocyte Count,3058504601,CDM,305,RC,85046,HCPCS,,,facility,both,,,,1.99,1.49,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Wbc White Blood Cell Count,3058504801,CDM,305,RC,85048,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Wbc White Blood Cell Count,3058504801,CDM,305,RC,85048,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Platelet Count, Automated",3058504901,CDM,305,RC,85049,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Platelet Count, Automated",3058504901,CDM,305,RC,85049,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Platelet Count, Automated",3058504901,CDM,305,RC,85049,HCPCS,,,facility,both,,,,4.93,3.7,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Platelet Count, Automated",3058504901,CDM,305,RC,85049,HCPCS,,,facility,both,,,,1.92,1.44,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Immature Platelet Fraction,3058505501,CDM,305,RC,85055,HCPCS,,,facility,both,,,,40.4,30.3,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Immature Platelet Fraction,3058505501,CDM,305,RC,85055,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immature Platelet Fraction,3058505501,CDM,305,RC,85055,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Immature Platelet Fraction,3058505501,CDM,305,RC,85055,HCPCS,,,facility,both,,,,40.4,30.3,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Blood Smear Peripheral Interp Phys W/Writ Report,3058506001,CDM,305,RC,85060,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Blood Smear Peripheral Interp Phys W/Writ Report,3058506001,CDM,305,RC,85060,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Blood Smear Peripheral Interp Phys W/Writ Report,3058506002,CDM,305,RC,85060,HCPCS,,,facility,both,,,,213,159.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Blood Smear Peripheral Interp Phys W/Writ Report,3058506002,CDM,305,RC,85060,HCPCS,,,facility,both,,,,213,159.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chromogenic Fviii (Ref Lab),3058513001,CDM,305,RC,85130,HCPCS,,,facility,both,,,,305,228.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chromogenic Fviii (Ref Lab),3058513001,CDM,305,RC,85130,HCPCS,,,facility,both,,,,305,228.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ch9-Chromogenic Fix, Plasma",3058513002,CDM,305,RC,85130,HCPCS,,,facility,both,,,,337,252.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ch9-Chromogenic Fix, Plasma",3058513002,CDM,305,RC,85130,HCPCS,,,facility,both,,,,337,252.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Chf8-Chromogenic Fviii, Plasma",3058513003,CDM,305,RC,85130,HCPCS,,,facility,both,,,,302,226.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Chf8-Chromogenic Fviii, Plasma",3058513003,CDM,305,RC,85130,HCPCS,,,facility,both,,,,302,226.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Coagulation Factor Ii Assay (Ref Lab),3058521001,CDM,305,RC,85210,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coagulation Factor Ii Assay (Ref Lab),3058521001,CDM,305,RC,85210,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  F_2-Coag Factor Ii Assay, P",3058521002,CDM,305,RC,85210,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  F_2-Coag Factor Ii Assay, P",3058521002,CDM,305,RC,85210,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coag Factor V Assay, P (Ref Lab)",3058522001,CDM,305,RC,85220,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coag Factor V Assay, P (Ref Lab)",3058522001,CDM,305,RC,85220,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Factv-Coag Factor V Assay, P",3058522003,CDM,305,RC,85220,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Factv-Coag Factor V Assay, P",3058522003,CDM,305,RC,85220,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Coagulation Factor Vii Assay (Ref Lab),3058523001,CDM,305,RC,85230,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coagulation Factor Vii Assay (Ref Lab),3058523001,CDM,305,RC,85230,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  F_7-Coag Factor Vii Assay, P",3058523002,CDM,305,RC,85230,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  F_7-Coag Factor Vii Assay, P",3058523002,CDM,305,RC,85230,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Coag Factor Viii Activ Assay,P (Ref Lab)",3058524001,CDM,305,RC,85240,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coag Factor Viii Activ Assay,P (Ref Lab)",3058524001,CDM,305,RC,85240,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  F8A-Coag Factor Viii Activity Assay, P",3058524002,CDM,305,RC,85240,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  F8A-Coag Factor Viii Activity Assay, P",3058524002,CDM,305,RC,85240,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058524003,CDM,305,RC,85240,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058524003,CDM,305,RC,85240,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo 8Inhe-Clotting Factor Viii Ahg 1 Stage,3058524005,CDM,305,RC,85240,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo 8Inhe-Clotting Factor Viii Ahg 1 Stage,3058524005,CDM,305,RC,85240,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ristocetin Co-Factor, Pi (Ref Lab)",3058524501,CDM,305,RC,85245,HCPCS,,,facility,both,,,,169,126.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ristocetin Co-Factor, Pi (Ref Lab)",3058524501,CDM,305,RC,85245,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rist-Ristocetin Cofactor, P",3058524502,CDM,305,RC,85245,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rist-Ristocetin Cofactor, P",3058524502,CDM,305,RC,85245,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Von Willebrand Factor Ag, P (Ref Lab)",3058524601,CDM,305,RC,85246,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Von Willebrand Factor Ag, P (Ref Lab)",3058524601,CDM,305,RC,85246,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058524602,CDM,305,RC,85246,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058524602,CDM,305,RC,85246,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Vwag-Von Willebrand Factor Ag, Plasma",3058524603,CDM,305,RC,85246,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Vwag-Von Willebrand Factor Ag, Plasma",3058524603,CDM,305,RC,85246,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058524604,CDM,305,RC,85246,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058524604,CDM,305,RC,85246,HCPCS,,,facility,both,,,,128,96,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Vwd8B-Vwd 2N (Normandy), Plasma",3058524606,CDM,305,RC,85246,HCPCS,,,facility,both,,,,1045,783.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Vwd8B-Vwd 2N (Normandy), Plasma",3058524606,CDM,305,RC,85246,HCPCS,,,facility,both,,,,1045,783.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Von Willebrand Fact Multimer,3058524701,CDM,305,RC,85247,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Von Willebrand Fact Multimer,3058524701,CDM,305,RC,85247,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Vwfmp-Von Willebrand Factor Multimer, P",3058524702,CDM,305,RC,85247,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Vwfmp-Von Willebrand Factor Multimer, P",3058524702,CDM,305,RC,85247,HCPCS,,,facility,both,,,,133,99.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Factor 9 Assay (Ref Lab),3058525001,CDM,305,RC,85250,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Factor 9 Assay (Ref Lab),3058525001,CDM,305,RC,85250,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Sacred Heart: Factor Ix,3058525002,CDM,305,RC,85250,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sacred Heart: Factor Ix,3058525002,CDM,305,RC,85250,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw57-Clotting Factor Ix Ptc/Christmas,3058525003,CDM,305,RC,85250,HCPCS,,,facility,both,,,,204,153,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw57-Clotting Factor Ix Ptc/Christmas,3058525003,CDM,305,RC,85250,HCPCS,,,facility,both,,,,204,153,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Factor 10 Assay (Ref Lab),3058526001,CDM,305,RC,85260,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Factor 10 Assay (Ref Lab),3058526001,CDM,305,RC,85260,HCPCS,,,facility,both,,,,62,46.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  F_10-Coag Factor X Assay, P",3058526002,CDM,305,RC,85260,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  F_10-Coag Factor X Assay, P",3058526002,CDM,305,RC,85260,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Coag Factor Xi Assay (Ref Lab),3058527001,CDM,305,RC,85270,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coag Factor Xi Assay (Ref Lab),3058527001,CDM,305,RC,85270,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  F_11-Coag Factor Xi Assay, P",3058527002,CDM,305,RC,85270,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  F_11-Coag Factor Xi Assay, P",3058527002,CDM,305,RC,85270,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo 11Ine-Clotting Factor Xi Pta,3058527003,CDM,305,RC,85270,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo 11Ine-Clotting Factor Xi Pta,3058527003,CDM,305,RC,85270,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Coag Factor Xii Assay (Ref Lab),3058528001,CDM,305,RC,85280,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coag Factor Xii Assay (Ref Lab),3058528001,CDM,305,RC,85280,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  F_12-Coag Factor Xii Assay, P",3058528002,CDM,305,RC,85280,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  F_12-Coag Factor Xii Assay, P",3058528002,CDM,305,RC,85280,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ffx3F-Factor Xiii, Functional",3058529001,CDM,305,RC,85290,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ffx3F-Factor Xiii, Functional",3058529001,CDM,305,RC,85290,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Albld-Clotting; Factor Xiii (Fibrin Stabilizing), Screen Solubility",3058529101,CDM,305,RC,85291,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Albld-Clotting; Factor Xiii (Fibrin Stabilizing), Screen Solubility",3058529101,CDM,305,RC,85291,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fa13Q-Clotting Factor Xiii Fibrn Stabiliz Screen Solub,3058529102,CDM,305,RC,85291,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fa13Q-Clotting Factor Xiii Fibrn Stabiliz Screen Solub,3058529102,CDM,305,RC,85291,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anti-Thrombin Iii Activity (Ref Lab),3058530001,CDM,305,RC,85300,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Thrombin Iii Activity (Ref Lab),3058530001,CDM,305,RC,85300,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Attf-Antithrombin Activ,Plasma (Ref Lab)",3058530002,CDM,305,RC,85300,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Attf-Antithrombin Activ,Plasma (Ref Lab)",3058530002,CDM,305,RC,85300,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Aathr-Thrombophilia Profile, Plasma And Whole Blood",3058530003,CDM,305,RC,85300,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Aathr-Thrombophilia Profile, Plasma And Whole Blood",3058530003,CDM,305,RC,85300,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anti-Thrombin Iii Antigen (Ref Lab),3058530101,CDM,305,RC,85301,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anti-Thrombin Iii Antigen (Ref Lab),3058530101,CDM,305,RC,85301,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Atti-Antithrombin Antigen, P",3058530103,CDM,305,RC,85301,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Atti-Antithrombin Antigen, P",3058530103,CDM,305,RC,85301,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Protein-C Antigen (Ref Lab),3058530201,CDM,305,RC,85302,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Protein-C Antigen (Ref Lab),3058530201,CDM,305,RC,85302,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Pcag-Protein C Ag, P",3058530202,CDM,305,RC,85302,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Pcag-Protein C Ag, P",3058530202,CDM,305,RC,85302,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Protein-C Activity (Ref Lab),3058530301,CDM,305,RC,85303,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Protein-C Activity (Ref Lab),3058530301,CDM,305,RC,85303,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Protein C Activity (Ref Lab),3058530302,CDM,305,RC,85303,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Protein C Activity (Ref Lab),3058530302,CDM,305,RC,85303,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Aathr-Clotting Inhibitors Or Anticoagulants; Protein C, Activity",3058530304,CDM,305,RC,85303,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Aathr-Clotting Inhibitors Or Anticoagulants; Protein C, Activity",3058530304,CDM,305,RC,85303,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Protein S Ag, Total, P (Ref Lab)",3058530501,CDM,305,RC,85305,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Protein S Ag, Total, P (Ref Lab)",3058530501,CDM,305,RC,85305,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Pst-Protein S Ag, Total, P",3058530502,CDM,305,RC,85305,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Pst-Protein S Ag, Total, P",3058530502,CDM,305,RC,85305,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Protein-S Activity (Ref Lab),3058530601,CDM,305,RC,85306,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Protein-S Activity (Ref Lab),3058530601,CDM,305,RC,85306,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Protein S Ag, Free (Ref Lab)",3058530602,CDM,305,RC,85306,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Protein S Ag, Free (Ref Lab)",3058530602,CDM,305,RC,85306,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Aathr-Clotting Inhibitors Or Anticoagulants; Protein S, Free",3058530604,CDM,305,RC,85306,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Aathr-Clotting Inhibitors Or Anticoagulants; Protein S, Free",3058530604,CDM,305,RC,85306,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  S_Fx-Protein S Activity, P",3058530605,CDM,305,RC,85306,HCPCS,,,facility,both,,,,88,66,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  S_Fx-Protein S Activity, P",3058530605,CDM,305,RC,85306,HCPCS,,,facility,both,,,,88,66,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Activated Protein Resistance V (Ref Lab),3058530701,CDM,305,RC,85307,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Activated Protein Resistance V (Ref Lab),3058530701,CDM,305,RC,85307,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Aathr-Activated Protein C (Apc) Resistance Assay,3058530702,CDM,305,RC,85307,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Aathr-Activated Protein C (Apc) Resistance Assay,3058530702,CDM,305,RC,85307,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Factor Vii Inhibitor Scrn (Ref Lab),3058533501,CDM,305,RC,85335,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Factor Vii Inhibitor Scrn (Ref Lab),3058533501,CDM,305,RC,85335,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chromogenic Fviii Inhib Titer (Ref Lab),3058533502,CDM,305,RC,85335,HCPCS,,,facility,both,,,,229,171.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  F8Is-Coag Factor Viii Assay Inhib Scrn,P",3058533503,CDM,305,RC,85335,HCPCS,,,facility,both,,,,245,183.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  F8Is-Coag Factor Viii Assay Inhib Scrn,P",3058533503,CDM,305,RC,85335,HCPCS,,,facility,both,,,,245,183.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  8Beth-Fviii Bethesda Units, P",3058533504,CDM,305,RC,85335,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  8Beth-Fviii Bethesda Units, P",3058533504,CDM,305,RC,85335,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  F5_Is-Factor V Inhib Scrn,3058533505,CDM,305,RC,85335,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  F5_Is-Factor V Inhib Scrn,3058533505,CDM,305,RC,85335,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  5Beth-Fv Bethesda Units, Plasma",3058533506,CDM,305,RC,85335,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  5Beth-Fv Bethesda Units, Plasma",3058533506,CDM,305,RC,85335,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  F9_Is-Factor Ix Inhib Scrn,3058533507,CDM,305,RC,85335,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  F9_Is-Factor Ix Inhib Scrn,3058533507,CDM,305,RC,85335,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  9Beth-Fix Bethesda Units, Plasma",3058533508,CDM,305,RC,85335,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  9Beth-Fix Bethesda Units, Plasma",3058533508,CDM,305,RC,85335,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Admis-Adamts13 Inhibitor Screen,3058533509,CDM,305,RC,85335,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Admis-Adamts13 Inhibitor Screen,3058533509,CDM,305,RC,85335,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Admbu-Adamts13 Inhibitor Bethesda Titer,3058533510,CDM,305,RC,85335,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Admbu-Adamts13 Inhibitor Bethesda Titer,3058533510,CDM,305,RC,85335,HCPCS,,,facility,both,,,,461,345.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Activated Clot Time (Hi- Range), Poc",3058534701,CDM,305,RC,85347,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Activated Clotting Time, Low Poc",3058534702,CDM,305,RC,85347,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Activated Clot Time, Ch1&2 Poc",3058534703,CDM,305,RC,85347,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Activated Clot Time, Ch3&4",3058534704,CDM,305,RC,85347,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Activated Clot Time, Ch5&6 Poc",3058534705,CDM,305,RC,85347,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Activated Clotting Time (Poc),3058534706,CDM,305,RC,85347,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Activated Clot Time (Hi- Range),3058534707,CDM,305,RC,85347,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Activated Clotting Time,3058534708,CDM,305,RC,85347,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Feuct-Euglobulin Clot Lysis Time,3058536001,CDM,305,RC,85360,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Feuct-Euglobulin Clot Lysis Time,3058536001,CDM,305,RC,85360,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Soluble Fibrin Monomer (Ref Lab),3058536601,CDM,305,RC,85366,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Soluble Fibrin Monomer (Ref Lab),3058536601,CDM,305,RC,85366,HCPCS,,,facility,both,,,,140,105,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Sfm-Soluble Fibrin Monomer (Ref Lab),3058536602,CDM,305,RC,85366,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sfm-Soluble Fibrin Monomer (Ref Lab),3058536602,CDM,305,RC,85366,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Solfm-Soluble Fibrin Monomer,3058536603,CDM,305,RC,85366,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Solfm-Soluble Fibrin Monomer,3058536603,CDM,305,RC,85366,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Solfm-Soluble Fibrin Monomer, Plasma",3058536604,CDM,305,RC,85366,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Solfm-Soluble Fibrin Monomer, Plasma",3058536604,CDM,305,RC,85366,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc D-Dimer (Ref Lab),3058537901,CDM,305,RC,85379,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc D-Dimer (Ref Lab),3058537901,CDM,305,RC,85379,HCPCS,,,facility,both,,,,115,86.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Aathr-Fibrin Degradation Products, D-Dimer; Quantitative",3058537903,CDM,305,RC,85379,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Aathr-Fibrin Degradation Products, D-Dimer; Quantitative",3058537903,CDM,305,RC,85379,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Dimer-D-Dimer, Plasma",3058537904,CDM,305,RC,85379,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Dimer-D-Dimer, Plasma",3058537904,CDM,305,RC,85379,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc D-Dimer Test, Ultrasensitive",3058538001,CDM,305,RC,85380,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc D-Dimer Test, Ultrasensitive",3058538001,CDM,305,RC,85380,HCPCS,,,facility,both,,,,15.36,11.52,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc D-Dimer Test, Ultrasensitive",3058538001,CDM,305,RC,85380,HCPCS,,,facility,both,,,,6.33,4.75,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc D-Dimer Test, Ultrasensitive",3058538001,CDM,305,RC,85380,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fibrinogen Activity,3058538401,CDM,305,RC,85384,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fibrinogen Activity,3058538401,CDM,305,RC,85384,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fibrinogen Activity,3058538401,CDM,305,RC,85384,HCPCS,,,facility,both,,,,25.19,18.89,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Fibrinogen Activity,3058538401,CDM,305,RC,85384,HCPCS,,,facility,both,,,,10.69,8.02,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Fibrinogen Activity,3058538401,CDM,305,RC,85384,HCPCS,,,facility,both,,,,3.16,2.37,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Fibrinogen (Ref Lab),3058538402,CDM,305,RC,85384,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fibrinogen (Ref Lab),3058538402,CDM,305,RC,85384,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Aathr-Fibrinogen; Activity,3058538403,CDM,305,RC,85384,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Aathr-Fibrinogen; Activity,3058538403,CDM,305,RC,85384,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Clfib-Fibrinogen, Clauss, Plasma",3058538404,CDM,305,RC,85384,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Clfib-Fibrinogen, Clauss, Plasma",3058538404,CDM,305,RC,85384,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ptfib-Pt-Fibrinogen, P",3058538501,CDM,305,RC,85385,HCPCS,,,facility,both,,,,148,111,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ptfib-Pt-Fibrinogen, P",3058538501,CDM,305,RC,85385,HCPCS,,,facility,both,,,,148,111,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Special Coagulation Interp (Ref Lab),3058539001,CDM,305,RC,85390,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Special Coagulation Interp (Ref Lab),3058539001,CDM,305,RC,85390,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chromogenic Fviii Inhib Interp (Ref Lab),3058539002,CDM,305,RC,85390,HCPCS,,,facility,both,,,,275,206.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chromogenic Fviii Inhib Interp (Ref Lab),3058539002,CDM,305,RC,85390,HCPCS,,,facility,both,,,,275,206.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Alupp Fibrinolysins Screen I&R,3058539003,CDM,305,RC,85390,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Alupp Fibrinolysins Screen I&R,3058539003,CDM,305,RC,85390,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Avwpq-Von Willebrand Disease Interp,3058539004,CDM,305,RC,85390,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Avwpq-Von Willebrand Disease Interp,3058539004,CDM,305,RC,85390,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Aathr-Fibrinolysins Or Coagulopathy Screen, Interpretation And Report",3058539005,CDM,305,RC,85390,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Aathr-Fibrinolysins Or Coagulopathy Screen, Interpretation And Report",3058539005,CDM,305,RC,85390,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Alupo-Lupus Anticoagulant Interpretation,3058539006,CDM,305,RC,85390,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Alupo-Lupus Anticoagulant Interpretation,3058539006,CDM,305,RC,85390,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058539007,CDM,305,RC,85390,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058539007,CDM,305,RC,85390,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo 11Ine-Fibrinolysins/Coagulopathy Screen Interp&Repor,3058539008,CDM,305,RC,85390,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo 11Ine-Fibrinolysins/Coagulopathy Screen Interp&Repor,3058539008,CDM,305,RC,85390,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo 8Inhe-Fibrinolysins Or Coagulopathy Screen, Interpretation And Report",3058539009,CDM,305,RC,85390,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo 8Inhe-Fibrinolysins Or Coagulopathy Screen, Interpretation And Report",3058539009,CDM,305,RC,85390,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Adamts13 Activity,3058539701,CDM,305,RC,85397,HCPCS,,,facility,both,,,,275,206.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Adamts13 Activity,3058539701,CDM,305,RC,85397,HCPCS,,,facility,both,,,,165,123.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Von Willebrand Factor Activ, P",3058539702,CDM,305,RC,85397,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Von Willebrand Factor Activ, P",3058539702,CDM,305,RC,85397,HCPCS,,,facility,both,,,,160,120,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Adm13-Adamts13 Activity And Inhibitor Profile,3058539703,CDM,305,RC,85397,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Adm13-Adamts13 Activity And Inhibitor Profile,3058539703,CDM,305,RC,85397,HCPCS,,,facility,both,,,,165,123.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Vwact-Von Willebrand Factor Activity, Plasma",3058539704,CDM,305,RC,85397,HCPCS,,,facility,both,,,,193,144.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Vwact-Von Willebrand Factor Activity, Plasma",3058539704,CDM,305,RC,85397,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058539705,CDM,305,RC,85397,HCPCS,,,facility,both,,,,192,144,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Avwpr-Von Willebrand Disease Profile, Plasma",3058539705,CDM,305,RC,85397,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Coagulation And Fibrinolysis, Functional Activity, Not Otherwise Specified (Eg, Adamts-13), Each Ana",3058539706,CDM,305,RC,85397,HCPCS,,,facility,both,,,,344,258,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fetal Screen,3058546001,CDM,305,RC,85460,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fetal Screen,3058546001,CDM,305,RC,85460,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kleihauer Stain For Fetal Hgb,3058546002,CDM,305,RC,85460,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kleihauer Stain For Fetal Hgb,3058546002,CDM,305,RC,85460,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hemoglobin Rbc Fetal For Fetomaternal Hemorrhage Rosette,3058546101,CDM,305,RC,85461,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hemoglobin Rbc Fetal For Fetomaternal Hemorrhage Rosette,3058546101,CDM,305,RC,85461,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Heparin/Protamine Titration, Poc",3058552001,CDM,305,RC,85520,HCPCS,,,facility,both,,,,239,179.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Heparin/Protamine Titration,3058552002,CDM,305,RC,85520,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Heparin Assay,3058552003,CDM,305,RC,85520,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Heparin Assay,3058552003,CDM,305,RC,85520,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Heparin Assay,3058552003,CDM,305,RC,85520,HCPCS,,,facility,both,,,,60.56,45.42,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Heparin Assay,3058552003,CDM,305,RC,85520,HCPCS,,,facility,both,,,,14.4,10.8,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Flyso - Lysozyme, Serum (Ref Lab)",3058554901,CDM,305,RC,85549,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flyso - Lysozyme, Serum (Ref Lab)",3058554901,CDM,305,RC,85549,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Osmotic Fragility (Ref Lab),3058555701,CDM,305,RC,85557,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Osmotic Fragility (Ref Lab),3058555701,CDM,305,RC,85557,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Osmotic Fragility Rbc Incubated,3058555702,CDM,305,RC,85557,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Osmotic Fragility Rbc Incubated,3058555702,CDM,305,RC,85557,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Platelet Function Screen,3058557601,CDM,305,RC,85576,HCPCS,,,facility,both,,,,160,120,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Platelet Function Screen,3058557601,CDM,305,RC,85576,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Platelet Function Screen,3058557601,CDM,305,RC,85576,HCPCS,,,facility,both,,,,27.4,20.55,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Platelet Function Screen,3058557601,CDM,305,RC,85576,HCPCS,,,facility,both,,,,4.79,3.59,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Platelet Function P2Y12,3058557602,CDM,305,RC,85576,HCPCS,,,facility,both,,,,160,120,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Platelet Function P2Y12,3058557602,CDM,305,RC,85576,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Platelet Function P2Y12,3058557602,CDM,305,RC,85576,HCPCS,,,facility,both,,,,27.4,20.55,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Platelet Neutralization (Ref Lab),3058559701,CDM,305,RC,85597,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Platelet Neutralization (Ref Lab),3058559701,CDM,305,RC,85597,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drvtt Confirm (Ref Lab),3058559702,CDM,305,RC,85597,HCPCS,,,facility,both,,,,88,66,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Pnp-Platelet Neutralization Procedure,3058559703,CDM,305,RC,85597,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Pnp-Platelet Neutralization Procedure,3058559703,CDM,305,RC,85597,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hexagonal Phosp Neutralization (Ref Lab),3058559801,CDM,305,RC,85598,HCPCS,,,facility,both,,,,160,120,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hexagonal Phosp Neutralization (Ref Lab),3058559801,CDM,305,RC,85598,HCPCS,,,facility,both,,,,160,120,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hexagonal Phase Confirm (Ref Lab),3058559802,CDM,305,RC,85598,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Staclot La, P (Ref Lab)",3058559803,CDM,305,RC,85598,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Staclot La, P (Ref Lab)",3058559803,CDM,305,RC,85598,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Stacl-Staclot La, P",3058559804,CDM,305,RC,85598,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Stacl-Staclot La, P",3058559804,CDM,305,RC,85598,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Stacl-Staclot Lupus Anticoagulant, Plasma",3058559805,CDM,305,RC,85598,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Stacl-Staclot Lupus Anticoagulant, Plasma",3058559805,CDM,305,RC,85598,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hexla-Phospholipid Neutralization; Hexagonal Phospholipid,3058559807,CDM,305,RC,85598,HCPCS,,,facility,both,,,,184,138,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prothrombin Time,3058561001,CDM,305,RC,85610,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prothrombin Time,3058561001,CDM,305,RC,85610,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Prothrombin Time,3058561001,CDM,305,RC,85610,HCPCS,,,facility,both,,,,23.01,17.26,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Prothrombin Time,3058561001,CDM,305,RC,85610,HCPCS,,,facility,both,,,,5.93,4.45,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Prothrombin Time,3058561001,CDM,305,RC,85610,HCPCS,,,facility,both,,,,1.91,1.43,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Prothrombin Time (Ref Lab),3058561002,CDM,305,RC,85610,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prothrombin Time (Ref Lab),3058561002,CDM,305,RC,85610,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Pt, Inr (Poc)",3058561003,CDM,305,RC,85610,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pt, Inr (Poc)",3058561003,CDM,305,RC,85610,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Kh Mayo Alupp Prothrombin Time,3058561005,CDM,305,RC,85610,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Alupp Prothrombin Time,3058561005,CDM,305,RC,85610,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Aathr-Prothrombin Time,3058561006,CDM,305,RC,85610,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Aathr-Prothrombin Time,3058561006,CDM,305,RC,85610,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Protime,3058561007,CDM,305,RC,85610,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Protime,3058561007,CDM,305,RC,85610,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Prothrombin Test (Pt) Mix 1:1 (Ref Lab),3058561101,CDM,305,RC,85611,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prothrombin Test (Pt) Mix 1:1,3058561102,CDM,305,RC,85611,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prothrombin Test (Pt) Mix 1:1,3058561102,CDM,305,RC,85611,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Ptmsc-Pt Mix 1:1,3058561103,CDM,305,RC,85611,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Ptmsc-Pt Mix 1:1,3058561103,CDM,305,RC,85611,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Drvvt Screen (Ref Lab),3058561301,CDM,305,RC,85613,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drvvt Mix (Ref Lab),3058561302,CDM,305,RC,85613,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drvtc - Drvvt Confirmation (Ref Lab),3058561303,CDM,305,RC,85613,HCPCS,,,facility,both,,,,88,66,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drvtc - Drvvt Confirmation (Ref Lab),3058561303,CDM,305,RC,85613,HCPCS,,,facility,both,,,,88,66,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Flupv Russell Viper Venom Diluted,3058561304,CDM,305,RC,85613,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Flupv Russell Viper Venom Diluted,3058561304,CDM,305,RC,85613,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Alupp Russell Viper Venom Diluted,3058561305,CDM,305,RC,85613,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Alupp Russell Viper Venom Diluted,3058561305,CDM,305,RC,85613,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Aathr-Russell Viper Venom Time (Includes Venom); Diluted,3058561306,CDM,305,RC,85613,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Aathr-Russell Viper Venom Time (Includes Venom); Diluted,3058561306,CDM,305,RC,85613,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Drv2-Drvvt Mix,3058561307,CDM,305,RC,85613,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Drv2-Drvvt Mix,3058561307,CDM,305,RC,85613,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Drv3-Drvvt Confirmation,3058561308,CDM,305,RC,85613,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Drv3-Drvvt Confirmation,3058561308,CDM,305,RC,85613,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fdvtx-Russell Viper Venom Time Diluted,3058561310,CDM,305,RC,85613,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fdvtx-Russell Viper Venom Time Diluted,3058561310,CDM,305,RC,85613,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Reptilase, Plasma (Ref Lab)",3058563501,CDM,305,RC,85635,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rtsc-Reptilase Time, P",3058563502,CDM,305,RC,85635,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rtsc-Reptilase Time, P",3058563502,CDM,305,RC,85635,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sed Rate, Erythrocyte",3058565101,CDM,305,RC,85651,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sed Rate, Erythrocyte",3058565101,CDM,305,RC,85651,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Sedimentation Rate Rbc Automated,3058565201,CDM,305,RC,85652,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sedimentation Rate Rbc Automated,3058565201,CDM,305,RC,85652,HCPCS,,,facility,both,,,,4.07,3.05,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Sedimentation Rate Rbc Automated,3058565201,CDM,305,RC,85652,HCPCS,,,facility,both,,,,2.13,1.6,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Hemoglobin S, Scrn, B (Ref Lab)",3058566001,CDM,305,RC,85660,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hemoglobin S, Scrn, B (Ref Lab)",3058566001,CDM,305,RC,85660,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hemoglobin S Test,3058566002,CDM,390,RC,85660,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thrombin Time (Ref Lab),3058567001,CDM,305,RC,85670,HCPCS,,,facility,both,,,,58,43.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thrombin Time (Bovine) (Ref Lab),3058567002,CDM,305,RC,85670,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thrombin Time (Bovine) (Ref Lab),3058567002,CDM,305,RC,85670,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Thrombin Clotting Time (Ref Lab),3058567003,CDM,305,RC,85670,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thrombin Clotting Time (Ref Lab),3058567003,CDM,305,RC,85670,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Aathr-Thrombin Time; Plasma,3058567004,CDM,305,RC,85670,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Aathr-Thrombin Time; Plasma,3058567004,CDM,305,RC,85670,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Ttsc-Thrombin Time (Bovine), Plasma",3058567005,CDM,305,RC,85670,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Ttsc-Thrombin Time (Bovine), Plasma",3058567005,CDM,305,RC,85670,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ptt,3058573001,CDM,305,RC,85730,HCPCS,,,facility,both,,,,1.99,1.49,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Ptt,3058573001,CDM,305,RC,85730,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ptt,3058573001,CDM,305,RC,85730,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ptt,3058573001,CDM,305,RC,85730,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Ptt,3058573001,CDM,305,RC,85730,HCPCS,,,facility,both,,,,8.1,6.08,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Activated Partial Thrombopl Tm (Ref Lab),3058573002,CDM,305,RC,85730,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Activated Partial Thrombopl Tm (Ref Lab),3058573002,CDM,305,RC,85730,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lupus Anticoagulant (Ref Lab),3058573003,CDM,305,RC,85730,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Alupp Thromboplastin Time Partial,3058573004,CDM,305,RC,85730,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Alupp Thromboplastin Time Partial,3058573004,CDM,305,RC,85730,HCPCS,,,facility,both,,,,11,8.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Flupv Thromboplastin Time Partial,3058573005,CDM,305,RC,85730,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Flupv Thromboplastin Time Partial,3058573005,CDM,305,RC,85730,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Aathr-Thromboplastin Time, Partial (Ptt); Plasma Or Whole Blood",3058573006,CDM,305,RC,85730,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Aathr-Thromboplastin Time, Partial (Ptt); Plasma Or Whole Blood",3058573006,CDM,305,RC,85730,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Ptt,3058573007,CDM,305,RC,85730,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Ptt,3058573007,CDM,305,RC,85730,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aptt Mix 1:1 (Ref Lab),3058573201,CDM,305,RC,85732,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aptt 1:1 60 Min Incubation Mix  (Ref Lab),3058573202,CDM,305,RC,85732,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thromboplastin Time Prtl Substit Plasma Frctj Ea,3058573203,CDM,305,RC,85732,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Apmsc-Activated Partial Thromboplastin Time (Aptt) Mix 1:1, Plasma",3058573204,CDM,305,RC,85732,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Apmsc-Activated Partial Thromboplastin Time (Aptt) Mix 1:1, Plasma",3058573204,CDM,305,RC,85732,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Apmsc-Aptt Mix 1:1,3058573205,CDM,305,RC,85732,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Apmsc-Aptt Mix 1:1,3058573205,CDM,305,RC,85732,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Viscosity (Ref Lab),3058581001,CDM,305,RC,85810,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Viscosity (Ref Lab),3058581001,CDM,305,RC,85810,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chlamydia Trachomatis And Neisseria Gonorrhea Pcr On Cepheid,3060353U01,CDM,306,RC,0353U,HCPCS,,,facility,both,,,,218,163.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chlamydia Trachomatis And Neisseria Gonorrhea Pcr On Cepheid,3060353U01,CDM,306,RC,0353U,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
RIFAMPIN SOLR 1 EACH VIAL,30631,CDM,250,RC,MHS1MG,HCPCS,67457044560,NDC,facility,both,1,ME,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 300 MG CAPS,30633,CDM,250,RC,60687058601,NDC,,,facility,both,2,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 300 MG CAPS,30633,CDM,250,RC,60687058601,NDC,,,facility,both,1,UN,,10.05,7.54,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5ML SUSR,30648,CDM,250,RC,MHS5ML,HCPCS,93416173,NDC,facility,both,5,ML,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 15 MG TABS,3067,CDM,250,RC,51079096020,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 15 MG TABS,3067,CDM,250,RC,51079096020,NDC,,,facility,both,0.3333,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 15 MG TABS,3067,CDM,250,RC,51079096020,NDC,,,facility,both,4,UN,,2.89,2.17,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 15 MG TABS,3067,CDM,250,RC,51079096020,NDC,,,facility,both,0.5,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 15 MG TABS,3067,CDM,250,RC,51079096020,NDC,,,facility,both,1.5,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 15 MG TABS,3067,CDM,250,RC,51079096020,NDC,,,facility,both,2,UN,,4.82,3.62,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,68084012011,NDC,,,facility,both,1,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,51079008720,NDC,,,facility,both,1.5,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,68084012001,NDC,,,facility,both,1,UN,,7.91,5.93,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,51079008720,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,13107000334,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,68084012001,NDC,,,facility,both,0.5,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,68084012001,NDC,,,facility,both,1.5,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,68084012001,NDC,,,facility,both,2,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,13107000334,NDC,,,facility,both,1,UN,,6.66,5,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG TABS,3068,CDM,250,RC,13107000334,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Kh Non Mayo-Neogenomics: Ntrk Ngs Fusion Panel,3068119401,CDM,306,RC,81194,HCPCS,,,facility,both,,,,1164,873,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non Mayo-Neogenomics: Ntrk Ngs Fusion Panel,3068119401,CDM,306,RC,81194,HCPCS,,,facility,both,,,,1012,759,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Incyte: Measurement Of Rna Of Bacteria In Vaginal Fluid Specimen,3068151301,CDM,306,RC,81513,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incyte: Measurement Of Rna Of Bacteria In Vaginal Fluid Specimen,3068151301,CDM,306,RC,81513,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture Afb, Concentration (Ref Lab)",3068701501,CDM,306,RC,87015,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture Afb, Concentration (Ref Lab)",3068701501,CDM,306,RC,87015,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Concentration For Infect Agent (Ref Lab),3068701502,CDM,306,RC,87015,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Concentration For Infect Agent (Ref Lab),3068701502,CDM,306,RC,87015,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mycobacteria Culture, Concn (Ref Lab)",3068701503,CDM,306,RC,87015,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mycobacteria Culture, Concn (Ref Lab)",3068701503,CDM,306,RC,87015,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Concentrate Exam (Ref Lab),3068701504,CDM,306,RC,87015,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Concentrate Exam (Ref Lab),3068701504,CDM,306,RC,87015,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Concentration Of Fluid For Infectious Agents,3068701505,CDM,306,RC,87015,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Concentration Of Fluid For Infectious Agents,3068701505,CDM,306,RC,87015,HCPCS,,,facility,both,,,,10.08,7.56,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Concentration Of Fluid For Infectious Agents,3068701505,CDM,306,RC,87015,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Cycl-Cyclospora Stain, Feces",3068701507,CDM,306,RC,87015,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Cycl-Cyclospora Stain, Feces",3068701507,CDM,306,RC,87015,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Blood",3068704001,CDM,306,RC,87040,HCPCS,,,facility,both,,,,264,198,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Blood",3068704001,CDM,306,RC,87040,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Blood",3068704001,CDM,306,RC,87040,HCPCS,,,facility,both,,,,15.58,11.68,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Blood",3068704001,CDM,306,RC,87040,HCPCS,,,facility,both,,,,13.08,9.81,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Culture, Stool/Rectal",3068704501,CDM,306,RC,87045,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Stool/Rectal",3068704501,CDM,306,RC,87045,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Stool/Rectal",3068704501,CDM,306,RC,87045,HCPCS,,,facility,both,,,,10.38,7.78,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Stool Isolate Id, Plate 1",3068704601,CDM,306,RC,87046,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Stool Isolate Id, Plate 1",3068704601,CDM,306,RC,87046,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Stool Isolate Id, Plate 2",3068704602,CDM,306,RC,87046,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Stool Isolate Id, Plate 2",3068704602,CDM,306,RC,87046,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Stool Isolate Id, Plate 3",3068704603,CDM,306,RC,87046,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Stool Isolate Id, Plate 3",3068704603,CDM,306,RC,87046,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Shigc-Culture, Bacterial; Stool, Aerobic, Additional Pathogens, Isolation And Presumptive Id",3068704605,CDM,306,RC,87046,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Body Fluid",3068707001,CDM,306,RC,87070,HCPCS,,,facility,both,,,,39.65,29.74,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Culture, Body Fluid",3068707001,CDM,306,RC,87070,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Body Fluid",3068707001,CDM,306,RC,87070,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Body Fluid",3068707001,CDM,306,RC,87070,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Culture, Body Fluid",3068707001,CDM,306,RC,87070,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Ear",3068707002,CDM,306,RC,87070,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Ear",3068707002,CDM,306,RC,87070,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Ear",3068707002,CDM,306,RC,87070,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Eye",3068707003,CDM,306,RC,87070,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Eye",3068707003,CDM,306,RC,87070,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Eye",3068707003,CDM,306,RC,87070,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Genito-Uretheral",3068707004,CDM,306,RC,87070,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Genito-Uretheral",3068707004,CDM,306,RC,87070,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Genito-Uretheral",3068707004,CDM,306,RC,87070,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Respiratory",3068707005,CDM,306,RC,87070,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Respiratory",3068707005,CDM,306,RC,87070,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Respiratory",3068707005,CDM,306,RC,87070,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Respiratory",3068707005,CDM,306,RC,87070,HCPCS,,,facility,both,,,,5.07,3.8,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Culture, Routine",3068707006,CDM,306,RC,87070,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Routine",3068707006,CDM,306,RC,87070,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Routine",3068707006,CDM,306,RC,87070,HCPCS,,,facility,both,,,,39.65,29.74,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Culture, Routine",3068707006,CDM,306,RC,87070,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Wound, Deep, Aerobic",3068707007,CDM,306,RC,87070,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Wound, Deep, Aerobic",3068707007,CDM,306,RC,87070,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Wound, Deep, Aerobic",3068707007,CDM,306,RC,87070,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Wound, Superficial",3068707008,CDM,306,RC,87070,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Wound, Superficial",3068707008,CDM,306,RC,87070,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Wound, Superficial",3068707008,CDM,306,RC,87070,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Nasopharnygeal",3068707009,CDM,306,RC,87070,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Nasopharnygeal",3068707009,CDM,306,RC,87070,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Nasopharnygeal",3068707009,CDM,306,RC,87070,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Bacterial Cult,Cystic Fib,Resp (Ref Lab)",3068707010,CDM,306,RC,87070,HCPCS,,,facility,both,,,,179,134.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Aerobic Culture, Extended Incubation",3068707012,CDM,306,RC,87070,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Aerobic Culture, Extended Incubation",3068707012,CDM,306,RC,87070,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Aerobic Culture, Extended Incubation",3068707013,CDM,306,RC,87070,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Aerobic Culture, Extended Incubation",3068707013,CDM,306,RC,87070,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Aerobic Culture, Extended Incubation",3068707014,CDM,306,RC,87070,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Aerobic Culture, Extended Incubation",3068707014,CDM,306,RC,87070,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Cfrc-Bacterial Culture, Cystic Fibrosis",3068707015,CDM,306,RC,87070,HCPCS,,,facility,both,,,,180,135,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cfrc-Bacterial Culture, Cystic Fibrosis",3068707015,CDM,306,RC,87070,HCPCS,,,facility,both,,,,180,135,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture,Wound,Quant,Aerobic",3068707101,CDM,306,RC,87071,HCPCS,,,facility,both,,,,164,123,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture,Wound,Quant,Aerobic",3068707101,CDM,306,RC,87071,HCPCS,,,facility,both,,,,164,123,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture,Wound,Quant,Aerobic",3068707101,CDM,306,RC,87071,HCPCS,,,facility,both,,,,9.48,7.11,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Wound, Deep, Anaerob",3068707501,CDM,306,RC,87075,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Wound, Deep, Anaerob",3068707501,CDM,306,RC,87075,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Wound, Deep, Anaerob",3068707501,CDM,306,RC,87075,HCPCS,,,facility,both,,,,14.25,10.69,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Wound, Deep, Anaerob",3068707501,CDM,306,RC,87075,HCPCS,,,facility,both,,,,10.03,7.52,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Kh Anaerobic Culture,3068707502,CDM,306,RC,87075,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Anaerobic Culture,3068707502,CDM,306,RC,87075,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Anaerobic Culture,3068707503,CDM,306,RC,87075,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Anaerobic Culture,3068707503,CDM,306,RC,87075,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anaerobic Isolate Id,3068707601,CDM,306,RC,87076,HCPCS,,,facility,both,,,,103,77.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anaerobic Isolate Id,3068707601,CDM,306,RC,87076,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anaerobic Isolate Id,3068707601,CDM,306,RC,87076,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Anaerobic Isolate Id,3068707601,CDM,306,RC,87076,HCPCS,,,facility,both,,,,12.19,9.14,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Organism Ident, Anaerobic Bact (Ref Lab)",3068707604,CDM,306,RC,87076,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Organism Ident, Anaerobic Bact (Ref Lab)",3068707604,CDM,306,RC,87076,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Id Maldi-Tof Mass Spec Anaerob (Ref Lab),3068707605,CDM,306,RC,87076,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Organism Id",3068707701,CDM,306,RC,87077,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Organism Id",3068707701,CDM,306,RC,87077,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Organism Id",3068707701,CDM,306,RC,87077,HCPCS,,,facility,both,,,,44.1,33.08,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Culture, Organism Id",3068707701,CDM,306,RC,87077,HCPCS,,,facility,both,,,,12.19,9.14,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Aerobic Isolate Id,3068707702,CDM,306,RC,87077,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aerobic Isolate Id,3068707702,CDM,306,RC,87077,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Aerobic Isolate Id,3068707702,CDM,306,RC,87077,HCPCS,,,facility,both,,,,78.27,58.7,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Aerobic Isolate Id,3068707702,CDM,306,RC,87077,HCPCS,,,facility,both,,,,12.19,9.14,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Organism Refer For Id, Aerobic",3068707707,CDM,306,RC,87077,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Organism Refer For Id, Aerobic",3068707707,CDM,306,RC,87077,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ident By Maldi-Tof Mass Spec,3068707708,CDM,306,RC,87077,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bacteria Ident Gid1,3068707709,CDM,306,RC,87077,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Mrsa Screen",3068708101,CDM,306,RC,87081,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Mrsa Screen",3068708101,CDM,306,RC,87081,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Mrsa Screen",3068708101,CDM,306,RC,87081,HCPCS,,,facility,both,,,,7.44,5.58,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Yersinia",3068708102,CDM,306,RC,87081,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Yersinia",3068708102,CDM,306,RC,87081,HCPCS,,,facility,both,,,,7.44,5.58,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Yersinia",3068708102,CDM,306,RC,87081,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Beta Strep",3068708103,CDM,306,RC,87081,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Beta Strep",3068708103,CDM,306,RC,87081,HCPCS,,,facility,both,,,,7.44,5.58,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Beta Strep",3068708103,CDM,306,RC,87081,HCPCS,,,facility,both,,,,3.63,2.72,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Culture, Beta Strep",3068708103,CDM,306,RC,87081,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Legionella (Ref Lab)",3068708104,CDM,306,RC,87081,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Legionella (Ref Lab)",3068708104,CDM,306,RC,87081,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Strep Group B Culture,3068708105,CDM,306,RC,87081,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Strep Group B Culture,3068708105,CDM,306,RC,87081,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cdif-Culture, Presumptive, Pathogenic Organisms, Screening Only",3068708106,CDM,306,RC,87081,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cdif-Culture, Presumptive, Pathogenic Organisms, Screening Only",3068708106,CDM,306,RC,87081,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Brucb-Brucella Culture, Blood",3068708107,CDM,306,RC,87081,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Brucb-Brucella Culture, Blood",3068708107,CDM,306,RC,87081,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Urine",3068708601,CDM,306,RC,87086,HCPCS,,,facility,both,,,,3.96,2.97,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Culture, Urine",3068708601,CDM,306,RC,87086,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Urine",3068708601,CDM,306,RC,87086,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Culture, Urine",3068708601,CDM,306,RC,87086,HCPCS,,,facility,both,,,,8.88,6.66,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Skin Fungi Culture,3068710101,CDM,306,RC,87101,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Culture, Fungus, Other Source",3068710201,CDM,306,RC,87102,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Fungus, Other Source",3068710201,CDM,306,RC,87102,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Fungus, Other Source",3068710201,CDM,306,RC,87102,HCPCS,,,facility,both,,,,36.36,27.27,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Culture, Fungus, Other Source",3068710201,CDM,306,RC,87102,HCPCS,,,facility,both,,,,11.21,8.41,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Yeast",3068710202,CDM,306,RC,87102,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Yeast",3068710202,CDM,306,RC,87102,HCPCS,,,facility,both,,,,70,52.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Yeast",3068710202,CDM,306,RC,87102,HCPCS,,,facility,both,,,,11.21,8.41,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Culture, Fungus, Blood",3068710301,CDM,306,RC,87103,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture, Fungus, Blood",3068710301,CDM,306,RC,87103,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture, Fungus, Blood",3068710301,CDM,306,RC,87103,HCPCS,,,facility,both,,,,22.51,16.88,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Mayo Fbl-Fungal Culture, Blood",3068710302,CDM,306,RC,87103,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fbl-Fungal Culture, Blood",3068710302,CDM,306,RC,87103,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Yeast Id,3068710601,CDM,306,RC,87106,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Yeast Id,3068710601,CDM,306,RC,87106,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Yeast Id,3068710601,CDM,306,RC,87106,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Yeast Id,3068710601,CDM,306,RC,87106,HCPCS,,,facility,both,,,,15.58,11.68,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Id Maldi-Tof Mass Spec Yeast (Ref Lab),3068710603,CDM,306,RC,87106,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mold Id,3068710701,CDM,306,RC,87107,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mold Id,3068710701,CDM,306,RC,87107,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture Ref For Ident, Fungus (Ref Lab)",3068710702,CDM,306,RC,87107,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture Ref For Ident, Fungus (Ref Lab)",3068710702,CDM,306,RC,87107,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fungal Ident Panel B (Ref Lab),3068710703,CDM,306,RC,87107,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Id Maldi-Tof Mass Spec Fungi (Ref Lab),3068710704,CDM,306,RC,87107,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Culture Tubercle/Oth Acid-Fast Bacilli Any Isol,3068711601,CDM,306,RC,87116,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Culture Tubercle/Oth Acid-Fast Bacilli Any Isol,3068711601,CDM,306,RC,87116,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mycobacterial Culture, Blood (Ref Lab)",3068711602,CDM,306,RC,87116,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mycobacterial Culture, Blood (Ref Lab)",3068711602,CDM,306,RC,87116,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cult Refd Id, Mycobact/Nocardi (Ref Lab)",3068711801,CDM,306,RC,87118,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cult Refd Id, Mycobact/Nocardi (Ref Lab)",3068711801,CDM,306,RC,87118,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Id Maldi-Toff Mass Spec Afb (Ref Lab),3068711802,CDM,306,RC,87118,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Serologic Agglutination Id,3068714701,CDM,306,RC,87147,HCPCS,,,facility,both,,,,88,66,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Serologic Agglutination Id,3068714701,CDM,306,RC,87147,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mycobacteria Probe Ident Broth (Ref Lab),3068715001,CDM,306,RC,87150,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mycobacteria Probe Ident Broth (Ref Lab),3068715001,CDM,306,RC,87150,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Lctb-Identification Of Organisms By Genetic Analysis, Amplified Probe Technique",3068715002,CDM,306,RC,87150,HCPCS,,,facility,both,,,,127,95.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Lctb-Identification Of Organisms By Genetic Analysis, Amplified Probe Technique",3068715002,CDM,306,RC,87150,HCPCS,,,facility,both,,,,127,95.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Id By 16S Sequencing (Ref Lab),3068715301,CDM,306,RC,87153,HCPCS,,,facility,both,,,,134,100.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Id By 16S Sequencing (Ref Lab),3068715301,CDM,306,RC,87153,HCPCS,,,facility,both,,,,134,100.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bacterial Ident By Sequencing (Ref Lab),3068715302,CDM,306,RC,87153,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bacterial Ident By Sequencing (Ref Lab),3068715302,CDM,306,RC,87153,HCPCS,,,facility,both,,,,235,176.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc D2 Fungal Sequencing Ident (Ref Lab),3068715303,CDM,306,RC,87153,HCPCS,,,facility,both,,,,235,176.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc D2 Fungal Sequencing Ident (Ref Lab),3068715303,CDM,306,RC,87153,HCPCS,,,facility,both,,,,165,123.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mtb Pza Confirm, Pnca Sequence (Ref Lab)",3068715304,CDM,306,RC,87153,HCPCS,,,facility,both,,,,345,258.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mtb Pza Confirm, Pnca Sequence (Ref Lab)",3068715304,CDM,306,RC,87153,HCPCS,,,facility,both,,,,345,258.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anaerobe Identify By Seq Isan (Ref Lab),3068715305,CDM,306,RC,87153,HCPCS,,,facility,both,,,,235,176.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Anaerobe Identify By Seq Isan (Ref Lab),3068715305,CDM,306,RC,87153,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arthropod Identification,3068716801,CDM,306,RC,87168,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthropod Identification,3068716801,CDM,306,RC,87168,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Parasite Identification,3068716901,CDM,306,RC,87169,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Parasite Identification,3068716901,CDM,306,RC,87169,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Parasite Identification,3068716901,CDM,306,RC,87169,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Parasite Identification,3068716901,CDM,306,RC,87169,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Parasite Identification (Ref Lab),3068716902,CDM,306,RC,87169,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Parasite Identification (Ref Lab),3068716902,CDM,306,RC,87169,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pinworm Exam,3068717201,CDM,306,RC,87172,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pinworm Exam,3068717201,CDM,306,RC,87172,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pinworm Exam,3068717201,CDM,306,RC,87172,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Tissue Homogenization,3068717601,CDM,306,RC,87176,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tissue Homogenization,3068717601,CDM,306,RC,87176,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tissue Processing (Ref Lab),3068717602,CDM,306,RC,87176,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tissue Processing (Ref Lab),3068717602,CDM,306,RC,87176,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ova & Parasites, Direct Smears",3068717701,CDM,306,RC,87177,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ova & Parasites, Direct Smears",3068717701,CDM,306,RC,87177,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ova & Parasites, Direct Smears",3068717701,CDM,306,RC,87177,HCPCS,,,facility,both,,,,10,7.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Ova & Parasites, Direct Smears",3068717701,CDM,306,RC,87177,HCPCS,,,facility,both,,,,31.03,23.27,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Ova & Parasites Smears (Ref Lab),3068717702,CDM,306,RC,87177,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ova & Parasites Smears (Ref Lab),3068717702,CDM,306,RC,87177,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Susceptiblty Per Drug/Organism (Ref Lab),3068718101,CDM,306,RC,87181,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Susceptiblty Per Drug/Organism (Ref Lab),3068718101,CDM,306,RC,87181,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Susceptibility, Anaerobic, Mic (Ref Lab)",3068718102,CDM,306,RC,87181,HCPCS,,,facility,both,,,,57,42.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Susceptibility, Anaerobic, Mic (Ref Lab)",3068718102,CDM,306,RC,87181,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Etest Susceptibility Studies, Per Antimicrobial Agent",3068718103,CDM,306,RC,87181,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Etest Susceptibility Studies, Per Antimicrobial Agent",3068718103,CDM,306,RC,87181,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Susceptibility, Disk Method",3068718401,CDM,306,RC,87184,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Susceptibility, Disk Method",3068718401,CDM,306,RC,87184,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Susceptibility, Disk Method",3068718401,CDM,306,RC,87184,HCPCS,,,facility,both,,,,10.41,7.81,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Beta Lactamase Testing,3068718501,CDM,306,RC,87185,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Beta Lactamase Testing,3068718501,CDM,306,RC,87185,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Beta Lactamase Bla (Ref Lab),3068718502,CDM,306,RC,87185,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Carnb-Carbapenemase-Carba Np Test,3068718503,CDM,306,RC,87185,HCPCS,,,facility,both,,,,210,157.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Carnb-Carbapenemase-Carba Np Test,3068718503,CDM,306,RC,87185,HCPCS,,,facility,both,,,,210,157.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Sensitivity & Susceptability,3068718601,CDM,306,RC,87186,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sensitivity & Susceptability,3068718601,CDM,306,RC,87186,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Sensitivity & Susceptability,3068718601,CDM,306,RC,87186,HCPCS,,,facility,both,,,,18.87,14.15,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Sensitivity & Susceptability,3068718601,CDM,306,RC,87186,HCPCS,,,facility,both,,,,13.05,9.79,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Sensitivity & Susceptability,3068718601,CDM,306,RC,87186,HCPCS,,,facility,both,,,,9.74,7.3,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Susceptibility,Fungus,Ea Agent",3068718602,CDM,306,RC,87186,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Susceptibility,Fungus,Ea Agent",3068718602,CDM,306,RC,87186,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sensitivity,Mic-Per Organism (Ref Lab)",3068718603,CDM,306,RC,87186,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sensitivity,Mic-Per Organism (Ref Lab)",3068718603,CDM,306,RC,87186,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Susceptibility Slow Grower (Ref Lab),3068718604,CDM,306,RC,87186,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Susceptibility Slow Grower (Ref Lab),3068718604,CDM,306,RC,87186,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Susceptibility, Norcardia (Ref Lab)",3068718605,CDM,306,RC,87186,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Susceptibility, Norcardia (Ref Lab)",3068718605,CDM,306,RC,87186,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Antimicrobial Susceptibi Yeast (Ref Lab),3068718606,CDM,306,RC,87186,HCPCS,,,facility,both,,,,148,111,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Antimicrobial Susceptibi Yeast (Ref Lab),3068718606,CDM,306,RC,87186,HCPCS,,,facility,both,,,,148,111,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh National Jewish Ref Lab Ntm13- Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiv",3068718607,CDM,306,RC,87186,HCPCS,,,facility,both,,,,371,278.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh National Jewish Ref Lab Ntm13- Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiv",3068718607,CDM,306,RC,87186,HCPCS,,,facility,both,,,,371,278.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Zw83 Quest: Susceptiblty Stdy Antimicrbial Micro/Agar Dilutj,3068718608,CDM,306,RC,87186,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Zw83 Quest: Susceptiblty Stdy Antimicrbial Micro/Agar Dilutj,3068718608,CDM,306,RC,87186,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Zw191-Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or",3068718609,CDM,306,RC,87186,HCPCS,,,facility,both,,,,368,276,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Zw191-Evaluation Of Antimicrobial Drug (Antibiotic, Antifungal, Antiviral), Microdilution Or",3068718609,CDM,306,RC,87186,HCPCS,,,facility,both,,,,368,276,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Zw191 Mayo- Univ Tx-Tyler Micro Testing,3068718610,CDM,306,RC,87186,HCPCS,,,facility,both,,,,302,226.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Zw191 Mayo- Univ Tx-Tyler Micro Testing,3068718610,CDM,306,RC,87186,HCPCS,,,facility,both,,,,302,226.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mtb Complex Susp-Etham, Broth (Ref Lab)",3068718801,CDM,306,RC,87188,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mtb Complex Susp-Etham, Broth (Ref Lab)",3068718801,CDM,306,RC,87188,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mtb Complex Susp-Rifam, Broth (Ref Lab)",3068718802,CDM,306,RC,87188,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mtb Complex Susp-Rifam, Broth (Ref Lab)",3068718802,CDM,306,RC,87188,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mtb Complex Susp-Inh, Broth (Ref Lab)",3068718803,CDM,306,RC,87188,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mtb Complex Susp-Inh, Broth (Ref Lab)",3068718803,CDM,306,RC,87188,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Susceptibility,Mtb Complex Pza (Ref Lab)",3068718804,CDM,306,RC,87188,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Susceptibility,Mtb Complex Pza (Ref Lab)",3068718804,CDM,306,RC,87188,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Smear,Prim.Source,Rout.Stain",3068720501,CDM,306,RC,87205,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Smear,Prim.Source,Rout.Stain",3068720501,CDM,306,RC,87205,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Smear,Prim.Source,Rout.Stain",3068720501,CDM,306,RC,87205,HCPCS,,,facility,both,,,,6.45,4.84,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Smear,Prim.Source,Rout.Stain",3068720501,CDM,306,RC,87205,HCPCS,,,facility,both,,,,3.76,2.82,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Gram Stain,3068720502,CDM,306,RC,87205,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gram Stain,3068720502,CDM,306,RC,87205,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Gram Stain,3068720502,CDM,306,RC,87205,HCPCS,,,facility,both,,,,39.65,29.74,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Gram Stain,3068720502,CDM,306,RC,87205,HCPCS,,,facility,both,,,,6.45,4.84,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Kh Smear, Stain & In",3068720503,CDM,306,RC,87205,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Smear, Stain & In",3068720503,CDM,306,RC,87205,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture Afb, Acid Fast Smear (Ref Lab)",3068720601,CDM,306,RC,87206,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Culture Afb, Acid Fast Smear (Ref Lab)",3068720601,CDM,306,RC,87206,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Acid-Fast Smear Mycobacterium (Ref Lab),3068720602,CDM,306,RC,87206,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Acid-Fast Smear Mycobacterium (Ref Lab),3068720602,CDM,306,RC,87206,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Nocardia Stain (Ref Lab),3068720603,CDM,306,RC,87206,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nocardia Stain (Ref Lab),3068720603,CDM,306,RC,87206,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Pneumocystis Smear (Ref Lab),3068720604,CDM,306,RC,87206,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pneumocystis Smear (Ref Lab),3068720604,CDM,306,RC,87206,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Blood Parasites Smear,3068720701,CDM,306,RC,87207,HCPCS,,,facility,both,,,,6.6,4.95,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Blood Parasites Smear,3068720701,CDM,306,RC,87207,HCPCS,,,facility,both,,,,96,72,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Blood Parasites Smear,3068720701,CDM,306,RC,87207,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Blood Parasites Smear,3068720701,CDM,306,RC,87207,HCPCS,,,facility,both,,,,55.87,41.9,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Special Stain (Ref Lab),3068720702,CDM,306,RC,87207,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Filaria (Ref Lab),3068720703,CDM,306,RC,87207,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Cycl-Cyclospora Stain, Feces",3068720704,CDM,306,RC,87207,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Cycl-Cyclospora Stain, Feces",3068720704,CDM,306,RC,87207,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ova & Parasites, Trichrome Stn",3068720901,CDM,306,RC,87209,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Ova & Parasites, Trichrome Stn",3068720901,CDM,306,RC,87209,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ova & Parasites, Trichrome Stn",3068720901,CDM,306,RC,87209,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Stain Slide Exam (Ref Lab),3068720902,CDM,306,RC,87209,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Stain Slide Exam (Ref Lab),3068720902,CDM,306,RC,87209,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Complex Special Stain (Ref Lab),3068720903,CDM,306,RC,87209,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Complex Special Stain (Ref Lab),3068720903,CDM,306,RC,87209,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Wet Mount,3068721001,CDM,306,RC,87210,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Wet Mount,3068721001,CDM,306,RC,87210,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Wet Mount,3068721001,CDM,306,RC,87210,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Wet Mount,3068721001,CDM,306,RC,87210,HCPCS,,,facility,both,,,,6.4,4.8,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Direct Prep Exam (Ref Lab),3068721002,CDM,306,RC,87210,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Poc Koh Wetmount (Ppm),3068721003,CDM,306,RC,87210,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Koh Slide,3068722001,CDM,306,RC,87220,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Koh Slide,3068722001,CDM,306,RC,87220,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Koh Slide,3068722001,CDM,306,RC,87220,HCPCS,,,facility,both,,,,36,27,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Poc Skin Scraping (Ppm),3068722002,CDM,306,RC,87220,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Viral Culture, Respiratory (Ref Lab)",3068725201,CDM,306,RC,87252,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Viral Culture, Respiratory (Ref Lab)",3068725201,CDM,306,RC,87252,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Viral Culture, Non-Respiratory (Ref Lab)",3068725202,CDM,306,RC,87252,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Viral Culture, Non-Respiratory (Ref Lab)",3068725202,CDM,306,RC,87252,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tissue Culture Inoculation (Ref Lab),3068725203,CDM,306,RC,87252,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Additional Testing Virus Ident  (Ref Lab),3068725301,CDM,306,RC,87253,HCPCS,,,facility,both,,,,76,57,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tissue Culture Addl Ident  (Ref Lab),3068725302,CDM,306,RC,87253,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hsv Culture From Neonate Hsv-1 (Ref Lab),3068725401,CDM,306,RC,87254,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hsv Culture From Neonate Hsv-1 (Ref Lab),3068725401,CDM,306,RC,87254,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hsv Culture From Neonate Hsv-2 (Ref Lab),3068725402,CDM,306,RC,87254,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hsv Culture From Neonate Hsv-2 (Ref Lab),3068725402,CDM,306,RC,87254,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Viral Smear, Shell Vial (Ref Lab)",3068725403,CDM,306,RC,87254,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Viral Smear, Shell Vial (Ref Lab)",3068725403,CDM,306,RC,87254,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Legionella Antigen, Ur",3068727801,CDM,306,RC,87278,HCPCS,,,facility,both,,,,156,117,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Legionella Antigen, Ur",3068727801,CDM,306,RC,87278,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Legionella Antigen, Ur",3068727801,CDM,306,RC,87278,HCPCS,,,facility,both,,,,17.16,12.87,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Aspergillus Ag Bronchov Lavage (Ref Lab),3068730501,CDM,306,RC,87305,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Aspergillus Ag Bronchov Lavage (Ref Lab),3068730501,CDM,306,RC,87305,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspergillus Galactomannan Antg (Ref Lab),3068730502,CDM,306,RC,87305,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspergillus Galactomannan Antg (Ref Lab),3068730502,CDM,306,RC,87305,HCPCS,,,facility,both,,,,64,48,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cryptosporidium Antigen,3068732801,CDM,306,RC,87328,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cryptosporidium Antigen,3068732801,CDM,306,RC,87328,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cryptosporidium Antigen,3068732801,CDM,306,RC,87328,HCPCS,,,facility,both,,,,15.2,11.4,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Giardia Antigen,3068732901,CDM,306,RC,87329,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Giardia Antigen,3068732901,CDM,306,RC,87329,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Giardia Antigen,3068732901,CDM,306,RC,87329,HCPCS,,,facility,both,,,,24.05,18.04,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Giardia Antigen,3068732901,CDM,306,RC,87329,HCPCS,,,facility,both,,,,13.18,9.88,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc H.Pylori Antigen, Stool (Ref Lab)",3068733801,CDM,306,RC,87338,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc H.Pylori Antigen, Stool (Ref Lab)",3068733801,CDM,306,RC,87338,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Helico Pylori Antigen, Fecal  (Ref Lab)",3068733802,CDM,306,RC,87338,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis B Surface Antigen,3068734001,CDM,306,RC,87340,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis B Surface Antigen,3068734001,CDM,306,RC,87340,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatitis B Surface Antigen,3068734001,CDM,306,RC,87340,HCPCS,,,facility,both,,,,9.56,7.17,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Hepatitis B Surface Antigen,3068734001,CDM,306,RC,87340,HCPCS,,,facility,both,,,,15.59,11.69,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Hepatitis B Surface Antigen (Ref Lab),3068734002,CDM,306,RC,87340,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo  Phsm Hepatitis B Surface Ag Ia,3068734003,CDM,306,RC,87340,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo  Phsm Hepatitis B Surface Ag Ia,3068734003,CDM,306,RC,87340,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Chsbp Hepatitis B Surface Ag Ia,3068734004,CDM,306,RC,87340,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Chsbp Hepatitis B Surface Ag Ia,3068734004,CDM,306,RC,87340,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hepatitis B Surface Ag Confirm,3068734101,CDM,306,RC,87341,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis B Surface Ag Confirm,3068734101,CDM,306,RC,87341,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Histoplasma Antigen, Quant (Ref Lab)",3068738501,CDM,306,RC,87385,HCPCS,,,facility,both,,,,144,108,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Histoplasma Antigen, Quant (Ref Lab)",3068738501,CDM,306,RC,87385,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hiv1 & Hiv2 Ag & Ab Plasma (Ref Lab),3068738901,CDM,306,RC,87389,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hiv1 & Hiv2 Ag & Ab Plasma (Ref Lab),3068738901,CDM,306,RC,87389,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hiv1 Antigen With Hiv1 And Hiv2 Antibodies,3068738902,CDM,306,RC,87389,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hiv1 Antigen With Hiv1 And Hiv2 Antibodies,3068738902,CDM,306,RC,87389,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hiv-1 P24 Antigen,3068739101,CDM,306,RC,87391,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hiv-1 P24 Antigen,3068739101,CDM,306,RC,87391,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hiv-1 P24 Antigen,3068739101,CDM,306,RC,87391,HCPCS,,,facility,both,,,,26.62,19.96,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Rotavirus Antigen, Stool (Ref Lab)",3068742501,CDM,306,RC,87425,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rotavirus Antigen, Stool (Ref Lab)",3068742501,CDM,306,RC,87425,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Rotavirus Antigen, Stool",3068742502,CDM,306,RC,87425,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rotavirus Antigen, Stool",3068742502,CDM,306,RC,87425,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Rotavirus Antigen, Stool",3068742502,CDM,306,RC,87425,HCPCS,,,facility,both,,,,13.18,9.88,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Shiga-Like Toxin Test,3068742701,CDM,306,RC,87427,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Shiga-Like Toxin Test,3068742701,CDM,306,RC,87427,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Infectious Agent Antigen Detection By Immunoassay Technique, Qualitative Or Semiquantitative; Str",3068743001,CDM,306,RC,87430,HCPCS,,,facility,both,,,,132,99,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Infectious Agent Antigen Detection By Immunoassay Technique, Qualitative Or Semiquantitative; Str",3068743001,CDM,306,RC,87430,HCPCS,,,facility,both,,,,132,99,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Fungitell (Ref Lab),3068744901,CDM,306,RC,87449,HCPCS,,,facility,both,,,,143,107.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Hibag-Histoplasma/Blastoplasma Ag, Eia, Serum",3068744903,CDM,306,RC,87449,HCPCS,,,facility,both,,,,172,129,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Hibag-Histoplasma/Blastoplasma Ag, Eia, Serum",3068744903,CDM,306,RC,87449,HCPCS,,,facility,both,,,,172,129,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Univ Of Wa - Infectious Agent Detection By Nucleic Acid (Dna Or Rna); Bartonella Henselae And Bar,3068747101,CDM,306,RC,87471,HCPCS,,,facility,both,,,,500,375,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Univ Of Wa - Infectious Agent Detection By Nucleic Acid (Dna Or Rna); Bartonella Henselae And Bar,3068747101,CDM,306,RC,87471,HCPCS,,,facility,both,,,,500,375,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lyme By Pcr (Ref Lab),3068747601,CDM,306,RC,87476,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lyme By Pcr (Ref Lab),3068747601,CDM,306,RC,87476,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lyme Dis Dna Amp Probe (Ref Lab),3068747602,CDM,306,RC,87476,HCPCS,,,facility,both,,,,234,175.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pborr Lyme Dis Dna Amp Probe,3068747603,CDM,306,RC,87476,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pborr Lyme Dis Dna Amp Probe,3068747603,CDM,306,RC,87476,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Candida Dna Amp Probe,3068748101,CDM,306,RC,87481,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Candida Albicans, Naa (Ref Lab)",3068748102,CDM,306,RC,87481,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Candida Glabrata, Naa",3068748103,CDM,306,RC,87481,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Meningitis/Encephaltis Pnl,Pcr (Ref Lab)",3068748301,CDM,306,RC,87483,HCPCS,,,facility,both,,,,858,643.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Meningitis/Encephaltis Pnl,Pcr (Ref Lab)",3068748301,CDM,306,RC,87483,HCPCS,,,facility,both,,,,468,351,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chlamydia Trachomatis,3068749101,CDM,306,RC,87491,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Chlamydia Trachomatis,3068749101,CDM,306,RC,87491,HCPCS,,,facility,both,,,,207,155.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chlamydia Trachomatis,3068749101,CDM,306,RC,87491,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Chlamydia Trachomatis,3068749101,CDM,306,RC,87491,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Chlamydia Trachomatis,3068749101,CDM,306,RC,87491,HCPCS,,,facility,both,,,,33.09,24.82,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Chylmd Trach Dna Amp Probe (Ref Lab),3068749102,CDM,306,RC,87491,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cgrna Chlmyd Trach Dna Amp Probe,3068749103,CDM,306,RC,87491,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cgrna Chlmyd Trach Dna Amp Probe,3068749103,CDM,306,RC,87491,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C Difficile Dna By Pcr,3068749301,CDM,306,RC,87493,HCPCS,,,facility,both,,,,52.95,39.71,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc C Difficile Dna By Pcr,3068749301,CDM,306,RC,87493,HCPCS,,,facility,both,,,,24.6,18.45,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc C Difficile Dna By Pcr,3068749301,CDM,306,RC,87493,HCPCS,,,facility,both,,,,266,199.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc C Difficile Dna By Pcr,3068749301,CDM,306,RC,87493,HCPCS,,,facility,both,,,,149,111.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc C Difficile Dna By Pcr,3068749301,CDM,306,RC,87493,HCPCS,,,facility,both,,,,52.1,39.08,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Clostridium Difficile Tox, Pcr (Ref Lab)",3068749302,CDM,306,RC,87493,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Clostridium Difficile Tox, Pcr (Ref Lab)",3068749302,CDM,306,RC,87493,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Lcmv - Cytomegalovirus By Pcr (Ref Lab),3068749601,CDM,306,RC,87496,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lcmv - Cytomegalovirus By Pcr (Ref Lab),3068749601,CDM,306,RC,87496,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Viracor-Cmv Pcr Qual, Fecal (Ref Lab)",3068749602,CDM,306,RC,87496,HCPCS,,,facility,both,,,,343,257.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cmv Dna, Quant (Ref Lab)",3068749701,CDM,306,RC,87497,HCPCS,,,facility,both,,,,305,228.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cmv Dna, Quant (Ref Lab)",3068749701,CDM,306,RC,87497,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cmv Pcr Quant (Ref Lab),3068749702,CDM,306,RC,87497,HCPCS,,,facility,both,,,,525,393.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cmv Quant By Pcr (Ref Lab),3068749703,CDM,306,RC,87497,HCPCS,,,facility,both,,,,322,241.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Enterovirus By Pcr (Ref Lab),3068749801,CDM,306,RC,87498,HCPCS,,,facility,both,,,,287,215.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Enterovirus By Pcr (Ref Lab),3068749801,CDM,306,RC,87498,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Enterovirus Pcr (Ref Lab),3068749802,CDM,306,RC,87498,HCPCS,,,facility,both,,,,220,165,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Enterovirus Pcr (Ref Lab),3068749802,CDM,306,RC,87498,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Influenza A/B By Pcr,3068750201,CDM,306,RC,87502,HCPCS,,,facility,both,,,,320,240,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Influenza A/B By Pcr,3068750201,CDM,306,RC,87502,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Influenza A & B,3068750202,CDM,306,RC,87502,HCPCS,,,facility,both,,,,320,240,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Influenza A/B By Pcr (Poc),3068750203,CDM,306,RC,87502,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Influenza A/B By Pcr (Poc),3068750203,CDM,306,RC,87502,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Influenza Dna Amp Prob Addl,3068750301,CDM,306,RC,87503,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Gastro Pathogen Pnl,Pcr,Feces (Ref Lab)",3068750701,CDM,306,RC,87507,HCPCS,,,facility,both,,,,858,643.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gastro Pathogen Pnl,Pcr,Feces (Ref Lab)",3068750701,CDM,306,RC,87507,HCPCS,,,facility,both,,,,535,401.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Gardner Vag Dna Amp Probe,3068751101,CDM,306,RC,87511,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gardner Vag Dna Amp Probe,3068751101,CDM,306,RC,87511,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Hepatitis B Virus,Quant,Pcr (Ref Lab)",3068751701,CDM,306,RC,87517,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hepatitis B Virus,Quant,Pcr (Ref Lab)",3068751701,CDM,306,RC,87517,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hepatitis C Virus,Quant,Rt-Pcr (Ref Lab)",3068752201,CDM,306,RC,87522,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hepatitis C Virus,Quant,Rt-Pcr (Ref Lab)",3068752201,CDM,306,RC,87522,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hcv Rna Detect/Quant Rflx Geno (Ref Lab),3068752202,CDM,306,RC,87522,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hcv Rna Detect/Quant Rflx Geno (Ref Lab),3068752202,CDM,306,RC,87522,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hsv Dna Amp Probe,3068752901,CDM,306,RC,87529,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Herpes Simplex Virus Dna Type2 (Ref Lab),3068752902,CDM,306,RC,87529,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Herpes Simplex Virus Dna Type2 (Ref Lab),3068752902,CDM,306,RC,87529,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Herpes Simplex Virus Pcr (Ref Lab),3068752903,CDM,306,RC,87529,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hsv 1 Pcr, Blood (Ref Lab)",3068752904,CDM,306,RC,87529,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hsv 2 Pcr, Blood (Ref Lab)",3068752905,CDM,306,RC,87529,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Herpes Simplex Virus Dna Type1 (Ref Lab),3068752906,CDM,306,RC,87529,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Herpes Simplex Virus Dna Type1 (Ref Lab),3068752906,CDM,306,RC,87529,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fhs12 Hsv Dna Amp Probe,3068752907,CDM,306,RC,87529,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fhs12 Hsv Dna Amp Probe,3068752907,CDM,306,RC,87529,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Herpb Hsv Dna Amp Probe,3068752908,CDM,306,RC,87529,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Herpb Hsv Dna Amp Probe,3068752908,CDM,306,RC,87529,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Herpv Hsv Dna Amp Probe,3068752909,CDM,306,RC,87529,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Herpv Hsv Dna Amp Probe,3068752909,CDM,306,RC,87529,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fhs12 Hsv Dna Amp Probe,3068752910,CDM,306,RC,87529,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fhs12 Hsv Dna Amp Probe,3068752910,CDM,306,RC,87529,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Herpb Hsv Dna Amp Probe,3068752911,CDM,306,RC,87529,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Herpb Hsv Dna Amp Probe,3068752911,CDM,306,RC,87529,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Herpv Hsv Dna Amp Probe,3068752912,CDM,306,RC,87529,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Herpv Hsv Dna Amp Probe,3068752912,CDM,306,RC,87529,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Herpesvirus Hhv-6A & Hhv-6B (Ref Lab),3068753301,CDM,306,RC,87533,HCPCS,,,facility,both,,,,656,492,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Herpesvirus 6 Dna Quant Rt-Pcr (Ref Lab),3068753302,CDM,306,RC,87533,HCPCS,,,facility,both,,,,378,283.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Herpesvirus 6 Dna Quant Rt-Pcr (Ref Lab),3068753302,CDM,306,RC,87533,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Detection By Nucleic Acid (Dna Or Rna); Hiv-1, Amplified Probe Tech, Incl Reverse Trans (Ref Lab)",3068753501,CDM,306,RC,87535,HCPCS,,,facility,both,,,,96,72,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Detection By Nucleic Acid (Dna Or Rna); Hiv-1, Amplified Probe Tech, Incl Reverse Trans (Ref Lab)",3068753501,CDM,306,RC,87535,HCPCS,,,facility,both,,,,96,72,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hiv-1 Ultra Sens Quant By Pcr (Ref Lab),3068753601,CDM,306,RC,87536,HCPCS,,,facility,both,,,,304,228,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hivdq-Hiv-1 Rna Detect&Quant,P (Ref Lab)",3068753602,CDM,306,RC,87536,HCPCS,,,facility,both,,,,324,243,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hivdq-Hiv-1 Rna Detect&Quant,P (Ref Lab)",3068753602,CDM,306,RC,87536,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hivdq-Hiv-1 Rna Detect&Quant,P (Ref Lab)",3068753602,CDM,306,RC,87536,HCPCS,,,facility,both,,,,93.61,70.21,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Hiv-1 Rna Quant W Reflex To Hiv-1 Genotypic Drug Resistance To Protease And Rti (Ref Lab),3068753603,CDM,306,RC,87536,HCPCS,,,facility,both,,,,304,228,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hiv-1 Rna Quant W Reflex To Hiv-1 Genotypic Drug Resistance To Protease And Rti (Ref Lab),3068753603,CDM,306,RC,87536,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fhv2Q-Hiv-2 Dna/Rna Qualitative Real-Time Pcr,3068753801,CDM,306,RC,87538,HCPCS,,,facility,both,,,,333,249.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fhv2Q-Hiv-2 Dna/Rna Qualitative Real-Time Pcr,3068753801,CDM,306,RC,87538,HCPCS,,,facility,both,,,,333,249.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Fhv2Q Hiv-2 Proviral Dna,Qual",3068753802,CDM,306,RC,87538,HCPCS,,,facility,both,,,,333,249.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fhv2Q Hiv-2 Proviral Dna,Qual",3068753802,CDM,306,RC,87538,HCPCS,,,facility,both,,,,333,249.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Hip12-Hiv-1/Hiv-2 Rna Detect, Plasma",3068753803,CDM,306,RC,87538,HCPCS,,,facility,both,,,,96,72,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Hip12-Hiv-1/Hiv-2 Rna Detect, Plasma",3068753803,CDM,306,RC,87538,HCPCS,,,facility,both,,,,96,72,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Non Tb Mycobacteria By Pcr (Ref Lab),3068755101,CDM,306,RC,87551,HCPCS,,,facility,both,,,,419,314.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mycobact/Tuberculos Cmplx, Pcr (Ref Lab)",3068755601,CDM,306,RC,87556,HCPCS,,,facility,both,,,,159,119.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mycobact/Tuberculos Cmplx, Pcr (Ref Lab)",3068755601,CDM,306,RC,87556,HCPCS,,,facility,both,,,,159,119.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mtb Complex Pcr (Ref Lab),3068755602,CDM,306,RC,87556,HCPCS,,,facility,both,,,,232,174,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mtb Complex Pcr (Ref Lab),3068755602,CDM,306,RC,87556,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc U Of W - M Avium Complex Pcr (Ref Lab),3068756101,CDM,306,RC,87561,HCPCS,,,facility,both,,,,232,174,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc M. Genitalium Amp Probe,3068756301,CDM,306,RC,87563,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc M. Genitalium Amp Probe,3068756301,CDM,306,RC,87563,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Kh Mayo Amgen Mycoplasma Genitalium, Tma, Varies",3068756302,CDM,306,RC,87563,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Amgen Mycoplasma Genitalium, Tma, Varies",3068756302,CDM,306,RC,87563,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Incyte: Mycoplasma Genitalium,3068756303,CDM,306,RC,87563,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mycoplasma Pneumoniae By Pcr (Ref Lab),3068758101,CDM,306,RC,87581,HCPCS,,,facility,both,,,,220,165,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mycoplasma Pneumoniae By Pcr (Ref Lab),3068758101,CDM,306,RC,87581,HCPCS,,,facility,both,,,,220,165,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neisseria Gonorrhoeae,3068759101,CDM,306,RC,87591,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Neisseria Gonorrhoeae,3068759101,CDM,306,RC,87591,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neisseria Gonorrhoeae,3068759101,CDM,306,RC,87591,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Neisseria Gonorrhoeae,3068759101,CDM,306,RC,87591,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Neisseria Gonorrhoeae,3068759101,CDM,306,RC,87591,HCPCS,,,facility,both,,,,206,154.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc N.Gonorrhoeae Dna Amp Probe (Ref Lab),3068759102,CDM,306,RC,87591,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc N.Gonorrhoeae Dna Amp Probe (Ref Lab),3068759102,CDM,306,RC,87591,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cgrna N.Gonorrhoeae Dna Amp Prob,3068759103,CDM,306,RC,87591,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cgrna N.Gonorrhoeae Dna Amp Prob,3068759103,CDM,306,RC,87591,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Non-Mayo-Univ Of Wa: Monkeypox, Qualitative",3068759301,CDM,306,RC,87593,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Non-Mayo-Univ Of Wa: Monkeypox, Qualitative",3068759301,CDM,306,RC,87593,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hpv High-Risk Types,3068762401,CDM,306,RC,87624,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hpv High-Risk Types,3068762401,CDM,306,RC,87624,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Hpv Types 16 & 18 Only,3068762501,CDM,306,RC,87625,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Influenza A/B, Rsv By Pcr Labcorp",3068763101,CDM,306,RC,87631,HCPCS,,,facility,both,,,,401,300.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Influenza A/B, Rsv By Pcr Labcorp",3068763101,CDM,306,RC,87631,HCPCS,,,facility,both,,,,401,300.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Influenza A/B, Rsv By Pcr",3068763102,CDM,306,RC,87631,HCPCS,,,facility,both,,,,188,141,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Influenza A/B, Rsv By Pcr",3068763102,CDM,306,RC,87631,HCPCS,,,facility,both,,,,188,141,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Influenza A/B, Rsv By Pcr (Poc)",3068763103,CDM,306,RC,87631,HCPCS,,,facility,both,,,,188,141,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Poc-Rsv,3068763401,CDM,306,RC,87634,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sars-Cov-2 Covid-19 Amp Prb,3068763501,CDM,306,RC,87635,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sars-Cov-2 Covid-19 Amp Prb,3068763501,CDM,306,RC,87635,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Staphylococcus Aureus(Sa Mssa),3068764001,CDM,306,RC,87640,HCPCS,,,facility,both,,,,172,129,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Staphylococcus Aureus(Sa Mssa),3068764001,CDM,306,RC,87640,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mrsa Nasal Screen By Pcr,3068764101,CDM,306,RC,87641,HCPCS,,,facility,both,,,,48.01,36.01,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Mrsa Nasal Screen By Pcr,3068764101,CDM,306,RC,87641,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mrsa Nasal Screen By Pcr,3068764101,CDM,306,RC,87641,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mrsa Nasal Screen By Pcr,3068764101,CDM,306,RC,87641,HCPCS,,,facility,both,,,,52.95,39.71,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Staphylococcus Aureus (Mrsa),3068764102,CDM,306,RC,87641,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Staphylococcus Aureus (Mrsa),3068764102,CDM,306,RC,87641,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Strep A, Molecular",3068765101,CDM,306,RC,87651,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Strep A, Molecular",3068765101,CDM,306,RC,87651,HCPCS,,,facility,both,,,,52.95,39.71,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Strep A, Molecular Poc",3068765102,CDM,306,RC,87651,HCPCS,,,facility,both,,,,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Strep A Dna Amp Probe Poc,3068765103,CDM,306,RC,87651,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Strep A Dna Amp Probe Poc,3068765103,CDM,306,RC,87651,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Trichomonas Vaginalis,3068766101,CDM,306,RC,87661,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Trichomonas Vaginalis,3068766101,CDM,306,RC,87661,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Trichomonas Vaginalis,3068766101,CDM,306,RC,87661,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Trichomonas Vaginalis,3068766101,CDM,306,RC,87661,HCPCS,,,facility,both,,,,116,87,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Trichomonas By Apt (Ref Lab),3068766102,CDM,306,RC,87661,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Trichomonas By Apt (Ref Lab),3068766102,CDM,306,RC,87661,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tvrna-Trichomonas Vag Nuc Amp (Ref Lab),3068766103,CDM,306,RC,87661,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tvrna-Trichomonas Vag Nuc Amp (Ref Lab),3068766103,CDM,306,RC,87661,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fnsvg Trichomonas Vaginalis Amplif,3068766104,CDM,306,RC,87661,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fnsvg Trichomonas Vaginalis Amplif,3068766104,CDM,306,RC,87661,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Resp Syncytial Virus By Pcr,3068779801,CDM,306,RC,87798,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Resp Syncytial Virus By Pcr,3068779801,CDM,306,RC,87798,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Adenovirus,Moleculr Detect,Pcr (Ref Lab)",3068779802,CDM,306,RC,87798,HCPCS,,,facility,both,,,,242,181.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Adenovirus,Moleculr Detect,Pcr (Ref Lab)",3068779802,CDM,306,RC,87798,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc B.Pertussis/Parapertussis,Pcr (Ref Lab)",3068779803,CDM,306,RC,87798,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc B.Pertussis/Parapertussis,Pcr (Ref Lab)",3068779803,CDM,306,RC,87798,HCPCS,,,facility,both,,,,140,105,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ebv By Pcr (Ref Lab),3068779804,CDM,306,RC,87798,HCPCS,,,facility,both,,,,214,160.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ebv By Pcr (Ref Lab),3068779804,CDM,306,RC,87798,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Pneumocystis By Pcr, Qual (Ref Lab)",3068779805,CDM,306,RC,87798,HCPCS,,,facility,both,,,,133,99.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Pneumocystis By Pcr, Qual (Ref Lab)",3068779805,CDM,306,RC,87798,HCPCS,,,facility,both,,,,410,307.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Varicella Zoster By Pcr (Ref Lab),3068779806,CDM,306,RC,87798,HCPCS,,,facility,both,,,,165,123.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Varicella Zoster By Pcr (Ref Lab),3068779806,CDM,306,RC,87798,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc West Nile Virus Rna By Pcr (Ref Lab),3068779807,CDM,306,RC,87798,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc West Nile Virus Rna By Pcr (Ref Lab),3068779807,CDM,306,RC,87798,HCPCS,,,facility,both,,,,266,199.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Jc Virus By Pcr (Ref Lab),3068779808,CDM,306,RC,87798,HCPCS,,,facility,both,,,,206,154.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Jc Virus By Pcr (Ref Lab),3068779808,CDM,306,RC,87798,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Acanthamoeba Species Pcr (Ref Lab),3068779809,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Acanthamoeba Species Pcr (Ref Lab),3068779809,CDM,306,RC,87798,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Naegleria Fowleri Pcr (Ref Lab),3068779810,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Balamuthia Mandrillaris Pcr (Ref Lab),3068779811,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Balamuthia Mandrillaris Pcr (Ref Lab),3068779811,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Atopobium Vaginae (Ref Lab),3068779812,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Atopobium Vaginae (Ref Lab),3068779812,CDM,306,RC,87798,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bvab 2 (Ref Lab),3068779813,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bvab 2 (Ref Lab),3068779813,CDM,306,RC,87798,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Megasphaera 1 (Ref Lab),3068779814,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Megasphaera 1 (Ref Lab),3068779814,CDM,306,RC,87798,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Coccidioides Immitis/Posad Pcr (Ref Lab),3068779815,CDM,306,RC,87798,HCPCS,,,facility,both,,,,185,138.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Coccidioides Immitis/Posad Pcr (Ref Lab),3068779815,CDM,306,RC,87798,HCPCS,,,facility,both,,,,185,138.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Tropheryma Whip,Mol Detect,Pcr (Ref Lab)",3068779816,CDM,306,RC,87798,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tropheryma Whip,Mol Detect,Pcr (Ref Lab)",3068779816,CDM,306,RC,87798,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Borrelia Miyamotoi Detect, Pcr (Ref Lab)",3068779817,CDM,306,RC,87798,HCPCS,,,facility,both,,,,245,183.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Babesia Microti (Ref Lab),3068779818,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Babesia Microti (Ref Lab),3068779818,CDM,306,RC,87798,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Babesia Duncani (Ref Lab),3068779819,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Babesia Duncani (Ref Lab),3068779819,CDM,306,RC,87798,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Babesia Divergens/Mo-1 (Ref Lab),3068779820,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Babesia Divergens/Mo-1 (Ref Lab),3068779820,CDM,306,RC,87798,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anaplasma Phagocytophilium (Ref Lab),3068779821,CDM,306,RC,87798,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Anaplasma Phagocytophilium (Ref Lab),3068779821,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ehrlichia Chaffeensis (Ref Lab),3068779822,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ehrlichia Chaffeensis (Ref Lab),3068779822,CDM,306,RC,87798,HCPCS,,,facility,both,,,,80,60,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ehrlichia Ewingii/Canis (Ref Lab),3068779823,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ehrlichia Muris Eauclairensis (Ref Lab),3068779824,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc B. Miyamotoi Pcr, B (Ref Lab)",3068779825,CDM,306,RC,87798,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc B. Miyamotoi Pcr, B (Ref Lab)",3068779825,CDM,306,RC,87798,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Blastomyces Pcr (Ref Lab),3068779826,CDM,306,RC,87798,HCPCS,,,facility,both,,,,185,138.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histoplasma Pcr (Ref Lab),3068779827,CDM,306,RC,87798,HCPCS,,,facility,both,,,,375,281.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histoplasma Pcr (Ref Lab),3068779827,CDM,306,RC,87798,HCPCS,,,facility,both,,,,375,281.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Toxoplasma Gondii, Pcr, Blood (Ref Lab)",3068779828,CDM,306,RC,87798,HCPCS,,,facility,both,,,,236,177,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Toxoplasma Gondii, Pcr, Blood (Ref Lab)",3068779828,CDM,306,RC,87798,HCPCS,,,facility,both,,,,236,177,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc U Of W - Legionella Pcr (Ref Lab),3068779829,CDM,306,RC,87798,HCPCS,,,facility,both,,,,341,255.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc U Of W-Aspergillus Pcr Tissue (Ref Lab),3068779830,CDM,306,RC,87798,HCPCS,,,facility,both,,,,449,336.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Shiga Toxin, Molecular, Pcr, F (Ref Lab)",3068779831,CDM,306,RC,87798,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Shiga Toxin, Molecular, Pcr, F (Ref Lab)",3068779831,CDM,306,RC,87798,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspergillus Spp,3068779832,CDM,306,RC,87798,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspergillus Terreus,3068779833,CDM,306,RC,87798,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Id Bureau - Measles Pcr,3068779834,CDM,306,RC,87798,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspergillus Fumigatus,3068779835,CDM,306,RC,87798,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coxiella Burnetii (Q Fever), Molecular Detection, Pcr, Serum (Ref Lab)",3068779836,CDM,306,RC,87798,HCPCS,,,facility,both,,,,283,212.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Coxiella Burnetii (Q Fever), Molecular Detection, Pcr, Serum (Ref Lab)",3068779836,CDM,306,RC,87798,HCPCS,,,facility,both,,,,283,212.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Detect Agent Nos Dna Amp 1 (Ref Lab,3068779837,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Detect Agent Nos Dna Amp 2 (Ref Lab),3068779838,CDM,306,RC,87798,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779839,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779839,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779840,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779840,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779841,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779841,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779842,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779842,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779843,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779843,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779844,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779844,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779845,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779845,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779846,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Tkpnl Detect Agent Nos Dna Amp,3068779846,CDM,306,RC,87798,HCPCS,,,facility,both,,,,21,15.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pborr Detect Agent Nos Dna Amp,3068779847,CDM,306,RC,87798,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pborr Detect Agent Nos Dna Amp,3068779847,CDM,306,RC,87798,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Pborr Detect Agent Nos Dna Amp,3068779848,CDM,306,RC,87798,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Pborr Detect Agent Nos Dna Amp,3068779848,CDM,306,RC,87798,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fnsvg Detect Agent Nos Dna Amp,3068779849,CDM,306,RC,87798,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fnsvg Detect Agent Nos Dna Amp,3068779849,CDM,306,RC,87798,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fnsvg Detect Agent Nos Dna Amp,3068779850,CDM,306,RC,87798,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fnsvg Detect Agent Nos Dna Amp,3068779850,CDM,306,RC,87798,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fnsvg Detect Agent Nos Dna Amp,3068779851,CDM,306,RC,87798,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fnsvg Detect Agent Nos Dna Amp,3068779851,CDM,306,RC,87798,HCPCS,,,facility,both,,,,50,37.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Lnoro-Norovirus Pcr, Molecular Detection, Feces",3068779852,CDM,306,RC,87798,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Lnoro-Norovirus Pcr, Molecular Detection, Feces",3068779852,CDM,306,RC,87798,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Hpfrp-H. Pylori W/Clarithromycin Reistance Prediction, Pcr, Feces",3068779853,CDM,306,RC,87798,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Hpfrp-H. Pylori W/Clarithromycin Reistance Prediction, Pcr, Feces",3068779853,CDM,306,RC,87798,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Lcmsp-Microsporidia Pcr,3068779855,CDM,306,RC,87798,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Lcmsp-Microsporidia Pcr,3068779855,CDM,306,RC,87798,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh National Jewish Ref Lab Ntmdr- Detection Test By Nucleic Acid For Organism, Amplified Probe Te",3068779856,CDM,306,RC,87798,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh National Jewish Ref Lab Ntmdr- Detection Test By Nucleic Acid For Organism, Amplified Probe Te",3068779856,CDM,306,RC,87798,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Isba-Iadna Nos Amplified Probe Tq Each Organism,3068779857,CDM,306,RC,87798,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Isba-Iadna Nos Amplified Probe Tq Each Organism,3068779857,CDM,306,RC,87798,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Isngs-Iadna Nos Amplified Probe Tq Each Organism,3068779858,CDM,306,RC,87798,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Isngs-Iadna Nos Amplified Probe Tq Each Organism,3068779858,CDM,306,RC,87798,HCPCS,,,facility,both,,,,530,397.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw59-Vectra,3068779859,CDM,306,RC,87798,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw59-Vectra,3068779859,CDM,306,RC,87798,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Lmalp-Infectious Agent Detection By Nucleic Acid (Dna Or Rna), Not Otherwise Specified; Ampl",3068779860,CDM,306,RC,87798,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Urrp-Detection Test By Nucleic Acid For Organism, Amplified Probe Technique",3068779861,CDM,306,RC,87798,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Urrp-Detection Test By Nucleic Acid For Organism, Amplified Probe Technique",3068779861,CDM,306,RC,87798,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Mhrp-Detection Test By Nucleic Acid For Organism, Amplified Probe Technique",3068779862,CDM,306,RC,87798,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Rpmpm-Infectious Agent Detection By Nucleic Acid (Dna Or Rna), Not Otherwise Specified; Ampl",3068779863,CDM,306,RC,87798,HCPCS,,,facility,both,,,,220,165,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incyte: Mycoplasma Hominis,3068779864,CDM,306,RC,87798,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incyte: Ureaplasma Urealyticum,3068779865,CDM,306,RC,87798,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Measr - Infectious Agent Detection By Nucleic Acid (Dna Or Rna), Not Otherwise Specified; Am",3068779866,CDM,306,RC,87798,HCPCS,,,facility,both,,,,495,371.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Measr - Infectious Agent Detection By Nucleic Acid (Dna Or Rna), Not Otherwise Specified; Am",3068779866,CDM,306,RC,87798,HCPCS,,,facility,both,,,,495,371.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Univ Of Wa - Infectious Agent Detection By Nucleic Acid (Dna Or Rna), Not Otherwise Specified; Am",3068779867,CDM,306,RC,87798,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Univ Of Wa - Infectious Agent Detection By Nucleic Acid (Dna Or Rna), Not Otherwise Specified; Am",3068779867,CDM,306,RC,87798,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Parvp-Iadna Nos Amplified Probe Tq Each Organism,3068779868,CDM,306,RC,87798,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Parvp-Iadna Nos Amplified Probe Tq Each Organism,3068779868,CDM,306,RC,87798,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mumpr-Mumps Virus Pcr, Buccal",3068779869,CDM,306,RC,87798,HCPCS,,,facility,both,,,,495,371.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Mumpr-Mumps Virus Pcr, Buccal",3068779869,CDM,306,RC,87798,HCPCS,,,facility,both,,,,495,371.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Stfrp-Iadna Nos Amplified Probe Tq Each Organism,3068779870,CDM,306,RC,87798,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Stfrp-Iadna Nos Amplified Probe Tq Each Organism,3068779870,CDM,306,RC,87798,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bk Virus Pcr Qnt, Blood (Ref Lab)",3068779901,CDM,306,RC,87799,HCPCS,,,facility,both,,,,313,234.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bk Virus Pcr Qnt, Blood (Ref Lab)",3068779901,CDM,306,RC,87799,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bk Virus Pcr Qnt, Urine (Ref Lab)",3068779902,CDM,306,RC,87799,HCPCS,,,facility,both,,,,313,234.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bk Virus Pcr Qnt, Urine (Ref Lab)",3068779902,CDM,306,RC,87799,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Epsteinbarr Dna Detect/Quant,P (Ref Lab)",3068779903,CDM,306,RC,87799,HCPCS,,,facility,both,,,,334,250.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Epsteinbarr Dna Detect/Quant,P (Ref Lab)",3068779903,CDM,306,RC,87799,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Seattle Childrn -Ebv Pcr Quant (Ref Lab),3068779904,CDM,306,RC,87799,HCPCS,,,facility,both,,,,520,390,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Adenovirus Dna, Quant Rt, Pcr (Ref Lab)",3068779905,CDM,306,RC,87799,HCPCS,,,facility,both,,,,378,283.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Adenovirus Dna, Quant Rt, Pcr (Ref Lab)",3068779905,CDM,306,RC,87799,HCPCS,,,facility,both,,,,74,55.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Seattle Children-Adv Pcr Quant (Ref Lab),3068779906,CDM,306,RC,87799,HCPCS,,,facility,both,,,,618,463.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fhv8P-Herpes Virus 8 Dna, Quant Rt-Pcr",3068779908,CDM,306,RC,87799,HCPCS,,,facility,both,,,,383,287.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Fhv8P-Herpes Virus 8 Dna, Quant Rt-Pcr",3068779908,CDM,306,RC,87799,HCPCS,,,facility,both,,,,383,287.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fhv7P-Iadna Nos Quantification Each Organism,3068779909,CDM,306,RC,87799,HCPCS,,,facility,both,,,,369,276.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fhv7P-Iadna Nos Quantification Each Organism,3068779909,CDM,306,RC,87799,HCPCS,,,facility,both,,,,369,276.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Bctpcr Bacteria Pcr (Ref Lab),3068780101,CDM,306,RC,87801,HCPCS,,,facility,both,,,,330,247.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bctpcr Bacteria Pcr (Ref Lab),3068780101,CDM,306,RC,87801,HCPCS,,,facility,both,,,,330,247.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Brbps-Br Bacterial Pcr (Mayo) (Ref Lab),3068780102,CDM,306,RC,87801,HCPCS,,,facility,both,,,,368,276,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Brbps-Br Bacterial Pcr (Mayo) (Ref Lab),3068780102,CDM,306,RC,87801,HCPCS,,,facility,both,,,,368,276,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Bartonella, Pcr (Ref Lab)",3068780103,CDM,306,RC,87801,HCPCS,,,facility,both,,,,159,119.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Bartonella, Pcr (Ref Lab)",3068780103,CDM,306,RC,87801,HCPCS,,,facility,both,,,,140,105,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Broad-Range Pcs, Bacterial (Ref Lab)",3068780104,CDM,306,RC,87801,HCPCS,,,facility,both,,,,316,237,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Broad Range Pcr Fungus (Ref Lab),3068780105,CDM,306,RC,87801,HCPCS,,,facility,both,,,,515,386.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Zygomycete Pcr (Ref Lab),3068780106,CDM,306,RC,87801,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Legionella Species, Molecular Detection, Pcr, Varies (Ref Lab)",3068780107,CDM,306,RC,87801,HCPCS,,,facility,both,,,,159,119.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Legionella Species, Molecular Detection, Pcr, Varies (Ref Lab)",3068780107,CDM,306,RC,87801,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Fnsvg Detect Agnt Mult Dna Ampli,3068780108,CDM,306,RC,87801,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Fnsvg Detect Agnt Mult Dna Ampli,3068780108,CDM,306,RC,87801,HCPCS,,,facility,both,,,,102,76.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Ngs16S (Uw)-Bacterial Detection By 16S Ngs,3068780109,CDM,306,RC,87801,HCPCS,,,facility,both,,,,1204,903,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Ngs16S (Uw)-Bacterial Detection By 16S Ngs,3068780109,CDM,306,RC,87801,HCPCS,,,facility,both,,,,1204,903,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Bacterial Dna Detection By Pcr,3068780110,CDM,306,RC,87801,HCPCS,,,facility,both,,,,378,283.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Bacterial Dna Detection By Pcr,3068780110,CDM,306,RC,87801,HCPCS,,,facility,both,,,,378,283.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Enterobacterales Dna Detection,3068780111,CDM,306,RC,87801,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Enterobacterales Dna Detection,3068780111,CDM,306,RC,87801,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Bacterial Detection By 16S Ngs,3068780112,CDM,306,RC,87801,HCPCS,,,facility,both,,,,1204,903,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Bacterial Detection By 16S Ngs,3068780112,CDM,306,RC,87801,HCPCS,,,facility,both,,,,1204,903,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Fungal Dna Detection By Pcr,3068780113,CDM,306,RC,87801,HCPCS,,,facility,both,,,,616,462,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Fungal Dna Detection By Pcr,3068780113,CDM,306,RC,87801,HCPCS,,,facility,both,,,,536,402,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Leishmania Species Dna Detection,3068780114,CDM,306,RC,87801,HCPCS,,,facility,both,,,,385,288.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Univ Of Wa: Leishmania Species Dna Detection,3068780114,CDM,306,RC,87801,HCPCS,,,facility,both,,,,385,288.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Univ Of Wa: Cocdna Coccidioides Dna Detection By Pcr,3068780115,CDM,306,RC,87801,HCPCS,,,facility,both,,,,389,291.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Univ Of Wa: Hisdna Histoplasma Dna Detection By Pcr,3068780116,CDM,306,RC,87801,HCPCS,,,facility,both,,,,389,291.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Univ Of Wa - Infectious Agent Detection By Nucleic Acid (Dna Or Rna), Multiple Organisms; Amplifi",3068780117,CDM,306,RC,87801,HCPCS,,,facility,both,,,,329,246.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Univ Of Wa - Infectious Agent Detection By Nucleic Acid (Dna Or Rna), Multiple Organisms; Amplifi",3068780117,CDM,306,RC,87801,HCPCS,,,facility,both,,,,329,246.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mscsf-Iadna Multiple Organisms Amplified Probe Tq,3068780118,CDM,306,RC,87801,HCPCS,,,facility,both,,,,3300,2475,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mscsf-Iadna Multiple Organisms Amplified Probe Tq,3068780118,CDM,306,RC,87801,HCPCS,,,facility,both,,,,3300,2475,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Influenza B Antigen,3068780402,CDM,306,RC,87804,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hiv Antigen/Antibody, Combination Assay, Screening",3068780601,CDM,306,RC,87806,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hiv Antigen/Antibody, Combination Assay, Screening",3068780601,CDM,306,RC,87806,HCPCS,,,facility,both,,,,73,54.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Rotavirus Slide Test,3068789901,CDM,306,RC,87899,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rotavirus Slide Test,3068789901,CDM,306,RC,87899,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Strep Pneumo Antigen, Ur",3068789902,CDM,306,RC,87899,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Strep Pneumo Antigen, Ur",3068789902,CDM,306,RC,87899,HCPCS,,,facility,both,,,,83,62.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Strep Pneumo Antigen, Ur",3068789902,CDM,306,RC,87899,HCPCS,,,facility,both,,,,42.71,32.03,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
"Hc Strep Pneumo Antigen, Ur",3068789902,CDM,306,RC,87899,HCPCS,,,facility,both,,,,17.68,13.26,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Slfa-Cryptococcus Antigen, Ser",3068789903,CDM,306,RC,87899,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Slfa-Cryptococcus Antigen, Ser",3068789903,CDM,306,RC,87899,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Streptococcus Pneumoniae Antigen, Urine (Ref Lab)",3068789904,CDM,306,RC,87899,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Streptococcus Pneumoniae Antigen, Urine (Ref Lab)",3068789904,CDM,306,RC,87899,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Legionella Antigen, Urine (Ref Lab)",3068789905,CDM,306,RC,87899,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Legionella Antigen, Urine (Ref Lab)",3068789905,CDM,306,RC,87899,HCPCS,,,facility,both,,,,35,26.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Btpbf-Beta-Trace Protein, Body Fluid",3068790001,CDM,306,RC,87900,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Btpbf-Beta-Trace Protein, Body Fluid",3068790001,CDM,306,RC,87900,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hcvdr-Infectious Agent Drug Susceptibility Analysis,3068790002,CDM,306,RC,87900,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hiv-1 Genotypic Pr-Rt Resist,P (Ref Lab)",3068790101,CDM,306,RC,87901,HCPCS,,,facility,both,,,,630,472.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hiv-1 Genotypic Pr-Rt Resist,P (Ref Lab)",3068790101,CDM,306,RC,87901,HCPCS,,,facility,both,,,,505,378.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hepatitis C Virus Genotype, S (Ref Lab)",3068790201,CDM,306,RC,87902,HCPCS,,,facility,both,,,,153,114.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Hepatitis C Virus Genotype, S (Ref Lab)",3068790201,CDM,306,RC,87902,HCPCS,,,facility,both,,,,153,114.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hcvgr-Hcv Genotype Resolution,3068790202,CDM,306,RC,87902,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Hcvdr- Hcv Genotypic Drug Resistance,3068790203,CDM,306,RC,87902,HCPCS,,,facility,both,,,,585,438.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phenosense Entry Hiv Drug Res (Ref Lab),3068790301,CDM,306,RC,87903,HCPCS,,,facility,both,,,,836,627,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phenosense Entry Hiv Drug Res (Ref Lab),3068790301,CDM,306,RC,87903,HCPCS,,,facility,both,,,,836,627,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Cmvng-Cmv Antiviral Resistance By Ngs, P",3068791001,CDM,306,RC,87910,HCPCS,,,facility,both,,,,748,561,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Cmvng-Cmv Antiviral Resistance By Ngs, P",3068791001,CDM,306,RC,87910,HCPCS,,,facility,both,,,,748,561,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Fcmvr-Analysis Test By Nucleic Acid For Cytomegalovirus, Cytomegalovirus",3068791002,CDM,306,RC,87910,HCPCS,,,facility,both,,,,1221,915.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Fcmvr-Analysis Test By Nucleic Acid For Cytomegalovirus, Cytomegalovirus",3068791002,CDM,306,RC,87910,HCPCS,,,facility,both,,,,1221,915.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fazsp-Unlisted Microbiology Procedure: Azole Susceptibility Panel,3068799901,CDM,306,RC,87999,HCPCS,,,facility,both,,,,259,194.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fazsp-Unlisted Microbiology Procedure: Azole Susceptibility Panel,3068799901,CDM,306,RC,87999,HCPCS,,,facility,both,,,,259,194.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,904651961,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,51079008620,NDC,,,facility,both,3,UN,,2.9,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,904651961,NDC,,,facility,both,3,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,904651961,NDC,,,facility,both,1,UN,,6.89,5.17,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,13107003134,NDC,,,facility,both,2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,51079008620,NDC,,,facility,both,1.5,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,904651961,NDC,,,facility,both,1.5,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,51079008620,NDC,,,facility,both,2,UN,,3.87,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,13107003134,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,904651961,NDC,,,facility,both,2,UN,,3.98,2.98,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,13107003134,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,51079008620,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TABS,3069,CDM,250,RC,51079008620,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
SELEGILINE 5 MG TABS,30764,CDM,250,RC,60505343803,NDC,,,facility,both,1,UN,,10.5,7.88,,,,,,,,,,Gross Charge Type: Pharmacy
"Hc Urinalysis,Automated W/Micro",3078100101,CDM,307,RC,81001,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Urinalysis,Automated W/Micro",3078100101,CDM,307,RC,81001,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Urinalysis,Automated W/Micro",3078100101,CDM,307,RC,81001,HCPCS,,,facility,both,,,,31,23.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Urinalysis,Automated W/Micro",3078100101,CDM,307,RC,81001,HCPCS,,,facility,both,,,,5.25,3.94,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Urinalysis,Automated W/Micro",3078100101,CDM,307,RC,81001,HCPCS,,,facility,both,,,,2.75,2.06,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Kh Urinalysis, Complete W/Microscopic",3078100102,CDM,307,RC,81001,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Urinalysis, Complete W/Microscopic",3078100102,CDM,307,RC,81001,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Ph, Urine",3078100201,CDM,307,RC,81002,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ph, Urine",3078100201,CDM,307,RC,81002,HCPCS,,,facility,both,,,,19,14.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Urinalysis Nonauto W/O Scope (Poc),3078100202,CDM,307,RC,81002,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Urinalysis W/O Scope Tc (Poc),3078100203,CDM,307,RC,81002,HCPCS,,,facility,both,,,,6,4.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Urinalysis,Automated W/O Micro",3078100301,CDM,307,RC,81003,HCPCS,,,facility,both,,,,2.19,1.64,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
"Hc Urinalysis,Automated W/O Micro",3078100301,CDM,307,RC,81003,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Urinalysis,Automated W/O Micro",3078100301,CDM,307,RC,81003,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Urinalysis,Automated W/O Micro",3078100301,CDM,307,RC,81003,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Urinalysis,Automated W/O Micro (Poc)",3078100302,CDM,307,RC,81003,HCPCS,,,facility,both,,,,51,38.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Urinalysis,Automated W/O Micro (Poc)",3078100302,CDM,307,RC,81003,HCPCS,,,facility,both,,,,5,3.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Urinalysis,Automated W/O Micro (Poc)",3078100302,CDM,307,RC,81003,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Urinalysis, Dipstick",3078100303,CDM,307,RC,81003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Urinalysis, Dipstick",3078100303,CDM,307,RC,81003,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Adulterants Srvy,Chain Of Cust (Ref Lab)",3078100501,CDM,307,RC,81005,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Adulterants Srvy,Chain Of Cust (Ref Lab)",3078100501,CDM,307,RC,81005,HCPCS,,,facility,both,,,,18,13.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Specific Gravity, Urine",3078100502,CDM,307,RC,81005,HCPCS,,,facility,both,,,,56,42,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Specific Gravity, Urine",3078100502,CDM,307,RC,81005,HCPCS,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Eosinophil Smear, Urine",3078101501,CDM,307,RC,81015,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Eosinophil Smear, Urine",3078101501,CDM,307,RC,81015,HCPCS,,,facility,both,,,,30,22.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Eosinophil Smear, Urine",3078101501,CDM,307,RC,81015,HCPCS,,,facility,both,,,,5.15,3.86,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Pregnancy Test, Urine",3078102501,CDM,307,RC,81025,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pregnancy Test, Urine",3078102501,CDM,307,RC,81025,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Pregnancy Test, Urine",3078102501,CDM,307,RC,81025,HCPCS,,,facility,both,,,,8.27,6.2,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
"Hc Pregnancy Test, Urine",3078102501,CDM,307,RC,81025,HCPCS,,,facility,both,,,,2.61,1.96,,,,,,,,,,Gross Charge Type: Fsc Labcorp 10815343_Unit Charge
Hc Urine Pregnancy Test (Poc),3078102502,CDM,307,RC,81025,HCPCS,,,facility,both,,,,16,12,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Pregnancy Test, Urine (Poc)",3078102503,CDM,307,RC,81025,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Urine Pregnancy Test Tc (Poc),3078102504,CDM,307,RC,81025,HCPCS,,,facility,both,,,,13,9.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
SERTRALINE 100 MG TABS,30791,CDM,250,RC,16714061304,NDC,,,facility,both,1,UN,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,16714061305,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,60687025301,NDC,,,facility,both,0.75,UN,,2.1,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,16714061301,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,904692661,NDC,,,facility,both,0.5,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,60687025301,NDC,,,facility,both,1,UN,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,16714061301,NDC,,,facility,both,2,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,904692661,NDC,,,facility,both,2,UN,,4.82,3.62,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,60687025301,NDC,,,facility,both,0.5,UN,,7.23,5.42,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,904692661,NDC,,,facility,both,1.25,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,16714061305,NDC,,,facility,both,1,UN,,5.46,4.1,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,60687025301,NDC,,,facility,both,1.5,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,49491041,NDC,,,facility,both,2,UN,,24.62,18.47,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,904692661,NDC,,,facility,both,1,UN,,7.85,5.89,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,16714061301,NDC,,,facility,both,1,UN,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,16714061305,NDC,,,facility,both,2,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,16714061305,NDC,,,facility,both,1.5,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,49491041,NDC,,,facility,both,1,UN,,29.85,22.39,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG TABS,30791,CDM,250,RC,60687025301,NDC,,,facility,both,2,UN,,4.8,3.6,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,60687024201,NDC,,,facility,both,4,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,65862001230,NDC,,,facility,both,1,UN,,3.83,2.87,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,49490041,NDC,,,facility,both,3,UN,,21.1,15.82,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,49490041,NDC,,,facility,both,2,UN,,22.85,17.14,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,60687024201,NDC,,,facility,both,0.5,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,49490041,NDC,,,facility,both,1.5,UN,,18.48,13.86,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,49490041,NDC,,,facility,both,1,UN,,28,21,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,60687024201,NDC,,,facility,both,3,UN,,3.23,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,904692561,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,60687024201,NDC,,,facility,both,1.5,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,60687024201,NDC,,,facility,both,2,UN,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,49490041,NDC,,,facility,both,0.5,UN,,18.6,13.95,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,60687024201,NDC,,,facility,both,2.5,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,60687024201,NDC,,,facility,both,0.25,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,60687024201,NDC,,,facility,both,1,UN,,6.29,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 50 MG TABS,30792,CDM,250,RC,904692561,NDC,,,facility,both,1,UN,,6.96,5.22,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG TABS,30825,CDM,250,RC,16714068202,NDC,,,facility,both,4,UN,,1.82,1.37,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG TABS,30825,CDM,250,RC,63739057110,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG TABS,30825,CDM,250,RC,16714068202,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG TABS,30825,CDM,250,RC,63739057110,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG TABS,30825,CDM,250,RC,16714068202,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG TABS,30825,CDM,250,RC,16714068202,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG TABS,30825,CDM,250,RC,63739057110,NDC,,,facility,both,3,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG TABS,30825,CDM,250,RC,63739057110,NDC,,,facility,both,4,UN,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG TABS,30825,CDM,250,RC,63739057110,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG TABS,30826,CDM,250,RC,16714068302,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG TABS,30826,CDM,250,RC,16714068302,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG TABS,30826,CDM,250,RC,63739057210,NDC,,,facility,both,1,UN,,6.77,5.08,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG TABS,30826,CDM,250,RC,63739057210,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG TABS,30826,CDM,250,RC,63739057210,NDC,,,facility,both,2,UN,,3.78,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG TABS,30826,CDM,250,RC,16714068302,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG TABS,30826,CDM,250,RC,63739057210,NDC,,,facility,both,4,UN,,2.18,1.63,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG TABS,30827,CDM,250,RC,63739057310,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG TABS,30827,CDM,250,RC,16714068402,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG TABS,30827,CDM,250,RC,63739057310,NDC,,,facility,both,2,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG TABS,30827,CDM,250,RC,63739057310,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG TABS,30827,CDM,250,RC,16714068402,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 5 MG TABS,30828,CDM,250,RC,63739057010,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 5 MG TABS,30828,CDM,250,RC,63739057010,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 5 MG TABS,30828,CDM,250,RC,63739057010,NDC,,,facility,both,4,UN,,2.14,1.6,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.28,UN,,135.8,101.85,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.5,UN,,203.3,152.48,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.49,UN,,200.2,150.15,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.36,UN,,160.45,120.34,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.328,UN,,150.55,112.91,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.39,UN,,169.5,127.12,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.43,UN,,181.65,136.24,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.26,UN,,129.7,97.28,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.42,UN,,178.6,133.95,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.4,UN,,172.5,129.38,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.29,UN,,138.9,104.18,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.272,UN,,133.4,100.05,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.31,UN,,145,108.75,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.392,UN,,170.1,127.58,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.58,UN,,228.25,171.19,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.308,UN,,144.4,108.3,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.25,UN,,126.65,94.99,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.37,UN,,163.5,122.62,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.35,UN,,157.4,118.05,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.6,UN,,234.4,175.8,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.52,UN,,209.55,157.16,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.544,UN,,217,162.75,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.34,UN,,154.3,115.72,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.362,UN,,161.05,120.79,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.46,UN,,190.9,143.18,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.32,UN,,148.1,111.08,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.382,UN,,167.1,125.32,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.54,UN,,215.75,161.81,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG/VIAL SOLR,30829,CDM,636,RC,J2805,HCPCS,270055615,NDC,facility,both,0.68,UN,,258.65,193.99,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500-334 MG/5ML SOLN,30860,CDM,250,RC,MHS1ML,HCPCS,121119000,NDC,facility,both,1,ML,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG SUPP,3087,CDM,250,RC,MHS1EA,HCPCS,57896044301,NDC,facility,both,1,EA,,20.15,15.11,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG SUPP,3087,CDM,250,RC,MHS1EA,HCPCS,574705012,NDC,facility,both,1,EA,,20.45,15.34,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG SUPP,3087,CDM,250,RC,MHS1EA,HCPCS,81421002101,NDC,facility,both,1,EA,,22.2,16.65,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE IRRIGATION 0.9 % SOLN,30886,CDM,250,RC,MHS500ML,HCPCS,990797208,NDC,facility,both,500,ML,,2.26,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE IRRIGATION 0.9 % SOLN,30886,CDM,250,RC,MHS500ML,HCPCS,990613822,NDC,facility,both,500,ML,,5.96,4.47,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE IRRIGATION 0.9 % SOLN,30886,CDM,250,RC,MHS500ML,HCPCS,990613803,NDC,facility,both,500,ML,,25.06,18.8,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE IRRIGATION 0.9 % SOLN,30886,CDM,250,RC,MHS500ML,HCPCS,338004802,NDC,facility,both,500,ML,,17.5,13.12,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE IRRIGATION 0.9 % SOLN,30886,CDM,250,RC,MHS500ML,HCPCS,990713836,NDC,facility,both,500,ML,,8.77,6.57,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE IRRIGATION 0.9 % SOLN,30886,CDM,250,RC,MHS500ML,HCPCS,264220110,NDC,facility,both,500,ML,,14.1,10.58,,,,,,,,,,Gross Charge Type: Pharmacy
"SODIUM CHLORIDE IRRIGATION 0.9 % SOLN 3,000 ML PLAS CONT",30886,CDM,250,RC,MHS500ML,HCPCS,990797208,NDC,facility,both,500,ML,,4.86,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE IRRIGATION 0.9 % SOLN 500 ML FLEX CONT,30886,CDM,250,RC,MHS500ML,HCPCS,990613803,NDC,facility,both,500,ML,,21.7,16.27,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOYL PEROXIDE 10 % LIQD,30910,CDM,250,RC,45802031834,NDC,,,facility,both,1,GR,,21.5,16.12,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOYL PEROXIDE 10 % LIQD,30910,CDM,250,RC,35573045408,NDC,,,facility,both,1,GR,,20.2,15.15,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25%  W/ EPI  MDV 2.5 MG/ML SOLN,30927,CDM,250,RC,MHS1ML,HCPCS,409175250,NDC,facility,both,1,ML,,2.47,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5%  W/ EPI  MDV 5 MG/ML SOLN,30928,CDM,250,RC,MHS1ML,HCPCS,409904601,NDC,facility,both,1,ML,,1.53,1.15,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % SOLN,30934,CDM,250,RC,67457016302,NDC,,,facility,both,2,ML,,248.95,186.71,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % SOLN,30934,CDM,250,RC,67457016302,NDC,,,facility,both,1,ML,,248.95,186.71,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % SOLN,30934,CDM,250,RC,67457016302,NDC,,,facility,both,8,ML,,236.21,177.16,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % SOLN,30934,CDM,250,RC,67457016302,NDC,,,facility,both,1.5,ML,,248.95,186.71,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % SOLN,30934,CDM,250,RC,67457016302,NDC,,,facility,both,4,ML,,229.88,172.41,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % SOLN,30934,CDM,250,RC,67457016302,NDC,,,facility,both,6,ML,,226.93,170.2,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 80 MG TABS,30954,CDM,250,RC,68084065401,NDC,,,facility,both,0.5,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 80 MG TABS,30954,CDM,250,RC,68084065401,NDC,,,facility,both,1.5,UN,,5.52,4.14,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 80 MG TABS,30954,CDM,250,RC,68084065401,NDC,,,facility,both,1,UN,,9.95,7.46,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 80 MG TABS,30954,CDM,250,RC,68084065401,NDC,,,facility,both,2,UN,,6.08,4.56,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 80 MG TABS,30954,CDM,250,RC,60505008000,NDC,,,facility,both,1,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 80 MG TABS,30954,CDM,250,RC,60505008000,NDC,,,facility,both,0.5,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 80 MG TABS,30954,CDM,250,RC,60505008000,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,68382066101,NDC,,,facility,both,0.5,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,63739054510,NDC,,,facility,both,3,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,63739054510,NDC,,,facility,both,2,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,63739054510,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,68382066101,NDC,,,facility,both,1,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,16714008502,NDC,,,facility,both,4,UN,,2.05,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,63739054510,NDC,,,facility,both,1.5,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,16714008502,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,68382066101,NDC,,,facility,both,2,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,16714008502,NDC,,,facility,both,2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,51079097920,NDC,,,facility,both,4,UN,,2.79,2.09,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,51079097920,NDC,,,facility,both,0.5,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,16714008502,NDC,,,facility,both,1,UN,,6.48,4.86,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,63739054510,NDC,,,facility,both,0.5,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,16714008502,NDC,,,facility,both,3,UN,,2.55,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,63739054510,NDC,,,facility,both,6,UN,,1.85,1.39,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,51079097920,NDC,,,facility,both,2,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,68382066101,NDC,,,facility,both,4,UN,,2.58,1.93,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,16714008502,NDC,,,facility,both,6,UN,,1.47,1.1,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,51079097920,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 50 MG TABS,30968,CDM,250,RC,63739054510,NDC,,,facility,both,4,UN,,2.49,1.87,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Mayo Fcmc-Drug Screening Cocaine,3098035301,CDM,309,RC,80353,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Fcmc-Drug Screening Cocaine,3098035301,CDM,309,RC,80353,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Ff10S-Drug Screening Fentanyl,3098035402,CDM,309,RC,80354,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Ff10S-Drug Screening Fentanyl,3098035402,CDM,309,RC,80354,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomics: Bcl-1 Translocation T(11:14),3098116801,CDM,309,RC,81168,HCPCS,,,facility,both,,,,422,316.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Bcl-1 Translocation T(11:14),3098116801,CDM,309,RC,81168,HCPCS,,,facility,both,,,,407,305.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cell Count Only, Body Fluid",3098905001,CDM,309,RC,89050,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cell Count Only, Body Fluid",3098905001,CDM,309,RC,89050,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cell Count Only, Body Fluid",3098905001,CDM,309,RC,89050,HCPCS,,,facility,both,,,,7.13,5.35,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
Hc Fat Stain,3098912501,CDM,309,RC,89125,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sweat Test,3098923001,CDM,309,RC,89230,HCPCS,,,facility,both,,,,340,255,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sweat Test,3098923001,CDM,309,RC,89230,HCPCS,,,facility,both,,,,132,99,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Semen Exam, Complete",3098932001,CDM,309,RC,89320,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Semen Exam, Complete",3098932001,CDM,309,RC,89320,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Sperm Count, Post Vas",3098932101,CDM,309,RC,89321,HCPCS,,,facility,both,,,,117,87.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sperm Count, Post Vas",3098932101,CDM,309,RC,89321,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
SUCRALFATE 1 GM/10ML SUSP,30993,CDM,250,RC,MHS10ML,HCPCS,121097400,NDC,facility,both,10,ML,,17.82,13.36,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 G TABS,30995,CDM,250,RC,51079075320,NDC,,,facility,both,1,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 G TABS,30995,CDM,250,RC,51079075320,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 G TABS,30995,CDM,250,RC,93221001,NDC,,,facility,both,1,UN,,7.7,5.78,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 G TABS,30995,CDM,250,RC,62135043690,NDC,,,facility,both,1,UN,,15.85,11.89,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 G TABS,30995,CDM,250,RC,29033000301,NDC,,,facility,both,1,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Amplified Dna Probe Detection Of Fungus In Blood Culture Specimen,3100140U01,CDM,310,RC,0140U,HCPCS,,,facility,both,,,,2248,1686,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amplified Dna Probe Detection Of Fungus In Blood Culture Specimen,3100140U01,CDM,310,RC,0140U,HCPCS,,,facility,both,,,,460,345,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hivdr-Gene Analysis Of Human Immunodeficiency Virus Targeted Sequence Analysis For Resistanc,3100219U01,CDM,310,RC,0219U,HCPCS,,,facility,both,,,,581,435.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,57896030401,NDC,,,facility,both,2,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,60687062201,NDC,,,facility,both,1,UN,,6.87,5.15,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,57896030401,NDC,,,facility,both,1,UN,,6.09,4.57,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,63739043202,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,57896030401,NDC,,,facility,both,4,UN,,1.61,1.21,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,63739043202,NDC,,,facility,both,1,UN,,6.31,4.73,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,536124801,NDC,,,facility,both,1,UN,,6.03,4.53,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,536124701,NDC,,,facility,both,1,UN,,6,4.5,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,536124701,NDC,,,facility,both,2,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,63739043201,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,536124810,NDC,,,facility,both,1,UN,,6.11,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,60687062201,NDC,,,facility,both,2,UN,,3.87,2.9,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,536124801,NDC,,,facility,both,2,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,536124810,NDC,,,facility,both,2,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA-DOCUSATE 8.6-50 MG TABS,31028,CDM,250,RC,63739043201,NDC,,,facility,both,2,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 17.5 MG/1 ML SUSP,3108,CDM,250,RC,1490010048,NDC,,,facility,both,30,ML,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 17.5 MG/1 ML SUSP 118 ML BOTTLE,3108,CDM,250,RC,1490003904,NDC,,,facility,both,118,ML,,49,36.75,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 17.5 MG/1 ML SUSP 473 ML BOTTLE,3108,CDM,250,RC,1490010048,NDC,,,facility,both,473,ML,,73.15,54.86,,,,,,,,,,Gross Charge Type: Pharmacy
"Hc Kh Mayo  Csmhu-Controlled Substance Monitoring Hybrid Drug Profile, 20 Drug Classes, High-Resolut",3108030720,CDM,310,RC,80307,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Csmhu-Controlled Substance Monitoring Hybrid Drug Profile, 20 Drug Classes, High-Resolut",3108030720,CDM,310,RC,80307,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Csmhu-Amphetamines; 5 Or More,3108032601,CDM,310,RC,80326,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Csmhu-Amphetamines; 5 Or More,3108032601,CDM,310,RC,80326,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Csmhu-Benzodiazepines; 13 Or More,3108034703,CDM,310,RC,80347,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Csmhu-Benzodiazepines; 13 Or More,3108034703,CDM,310,RC,80347,HCPCS,,,facility,both,,,,33,24.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Csmhu-Opioids And Opiate Analogs; 5 Or More,3108036402,CDM,310,RC,80364,HCPCS,,,facility,both,,,,23,17.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Csmhu-Opioids And Opiate Analogs; 5 Or More,3108036402,CDM,310,RC,80364,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pathology Consult (Ref Lab),3108050001,CDM,310,RC,80500,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Idh1 Mutations (Neogenomics),3108112001,CDM,310,RC,81120,HCPCS,,,facility,both,,,,384,288,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hematologics - Idh1 Exon 4,3108112002,CDM,310,RC,81120,HCPCS,,,facility,both,,,,437,327.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Idhq-Gene Analysis (Isocitrate Dehydrogenase 1 [Nadp+], Soluble) For Common Variants",3108112003,CDM,310,RC,81120,HCPCS,,,facility,both,,,,573,429.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Idhq-Gene Analysis (Isocitrate Dehydrogenase 1 [Nadp+], Soluble) For Common Variants",3108112003,CDM,310,RC,81120,HCPCS,,,facility,both,,,,573,429.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Idh2 Mutations (Neogenomics),3108112101,CDM,310,RC,81121,HCPCS,,,facility,both,,,,588,441,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hematologics - Idh2 Exon 4,3108112102,CDM,310,RC,81121,HCPCS,,,facility,both,,,,588,441,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Idhq-Gene Analysis (Isocitrate Dehydrogenase 2 [Nadp+], Mitochondrial) For Common Variant",3108112103,CDM,310,RC,81121,HCPCS,,,facility,both,,,,875,656.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Idhq-Gene Analysis (Isocitrate Dehydrogenase 2 [Nadp+], Mitochondrial) For Common Variant",3108112103,CDM,310,RC,81121,HCPCS,,,facility,both,,,,761,570.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Hbocz-Brca1/Brca2 Genes, Full Gene Analysis",3108116201,CDM,310,RC,81162,HCPCS,,,facility,both,,,,4425,3318.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Hbocz-Brca1/Brca2 Genes, Full Gene Analysis",3108116201,CDM,310,RC,81162,HCPCS,,,facility,both,,,,3681,2760.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Brca1 Brca2 Gene Alys Full Seq Full Dup/Del Alys,3108116202,CDM,310,RC,81162,HCPCS,,,facility,both,,,,673,504.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Brca1 Brca2 Gene Alys Full Seq Full Dup/Del Alys,3108116202,CDM,310,RC,81162,HCPCS,,,facility,both,,,,673,504.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomic-Asxl1 Mutation Anly (Ref Lab),3108117501,CDM,310,RC,81175,HCPCS,,,facility,both,,,,856,642,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Scap-Gene Analysis (Ataxin 1) For Abnormal Alleles,3108117801,CDM,310,RC,81178,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Scap-Gene Analysis (Ataxin 1) For Abnormal Alleles,3108117801,CDM,310,RC,81178,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Scap-Gene Analysis (Ataxin 2) For Abnormal Alleles,3108117901,CDM,310,RC,81179,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Scap-Gene Analysis (Ataxin 2) For Abnormal Alleles,3108117901,CDM,310,RC,81179,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Scap-Gene Analysis (Ataxin 3) For Abnormal Alleles,3108118001,CDM,310,RC,81180,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Scap-Gene Analysis (Ataxin 3) For Abnormal Alleles,3108118001,CDM,310,RC,81180,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Scap-Gene Analysis (Ataxin 7) For Abnormal Alleles,3108118101,CDM,310,RC,81181,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Scap-Gene Analysis (Ataxin 7) For Abnormal Alleles,3108118101,CDM,310,RC,81181,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Scap-Gene Analysis (Calcium Voltage-Gated Channel Subunit Alpha1 A) For Abnormal Alleles,3108118401,CDM,310,RC,81184,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Scap-Gene Analysis (Calcium Voltage-Gated Channel Subunit Alpha1 A) For Abnormal Alleles,3108118401,CDM,310,RC,81184,HCPCS,,,facility,both,,,,202,151.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Apc Gene Analysis Full Gene Sequence,3108120101,CDM,310,RC,81201,HCPCS,,,facility,both,,,,288,216,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Apc Gene Analysis Full Gene Sequence,3108120101,CDM,310,RC,81201,HCPCS,,,facility,both,,,,288,216,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bcrfx Bcr/Abl1 Gene Major Bp,3108120601,CDM,310,RC,81206,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Bcrfx Bcr/Abl1 Gene Major Bp,3108120601,CDM,310,RC,81206,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Badx Bcr/Abl1 Gene Major Bp,3108120602,CDM,310,RC,81206,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Badx Bcr/Abl1 Gene Major Bp,3108120602,CDM,310,RC,81206,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bcrfx Bcr/Abl1 Gene Minor Bp,3108120701,CDM,310,RC,81207,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Bcrfx Bcr/Abl1 Gene Minor Bp,3108120701,CDM,310,RC,81207,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Badx Bcr/Abl1 Gene Minor Bp,3108120702,CDM,310,RC,81207,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Badx Bcr/Abl1 Gene Minor Bp,3108120702,CDM,310,RC,81207,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bcrfx Bcr/Abl1 Gene Other Bp,3108120801,CDM,310,RC,81208,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Bcrfx Bcr/Abl1 Gene Other Bp,3108120801,CDM,310,RC,81208,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Badx Bcr/Abl1 Gene Other Bp,3108120802,CDM,310,RC,81208,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Badx Bcr/Abl1 Gene Other Bp,3108120802,CDM,310,RC,81208,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Braf Gene Analysis (Ref Lab),3108121001,CDM,310,RC,81210,HCPCS,,,facility,both,,,,380,285,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Braf Gene Analysis - Incyte (Ref Lab),3108121002,CDM,310,RC,81210,HCPCS,,,facility,both,,,,380,285,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cepba Gene Anlys, Hematologics (Ref Lab)",3108121801,CDM,310,RC,81218,HCPCS,,,facility,both,,,,380,285,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Calr Mutation Analysis,3108121901,CDM,310,RC,81219,HCPCS,,,facility,both,,,,373,279.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomics: Calr Mutation Analysis,3108121901,CDM,310,RC,81219,HCPCS,,,facility,both,,,,373,279.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cystic Fibrosis Mutation Analysis, 106-Mutation Panel, Varies (Ref Lab)",3108122001,CDM,310,RC,81220,HCPCS,,,facility,both,,,,213,159.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cystic Fibrosis Mutation Analysis, 106-Mutation Panel, Varies (Ref Lab)",3108122001,CDM,310,RC,81220,HCPCS,,,facility,both,,,,213,159.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Csfp-Cftr Gene Analysis Common Variants,3108122002,CDM,310,RC,81220,HCPCS,,,facility,both,,,,576,432,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Csfp-Cftr Gene Analysis Common Variants,3108122002,CDM,310,RC,81220,HCPCS,,,facility,both,,,,576,432,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cfmp Cystic Fibrosis (Cf) Mutation Panel,3108122201,CDM,310,RC,81222,HCPCS,,,facility,both,,,,192,144,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cfmp Cystic Fibrosis (Cf) Mutation Panel,3108122201,CDM,310,RC,81222,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Csfp-Cftr Gene Analysis Duplication/Deletion Variants,3108122202,CDM,310,RC,81222,HCPCS,,,facility,both,,,,451,338.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Csfp-Cftr Gene Analysis Duplication/Deletion Variants,3108122202,CDM,310,RC,81222,HCPCS,,,facility,both,,,,392,294,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hpanp-Cftr Gene Analysis Full Gene Sequence,3108122301,CDM,310,RC,81223,HCPCS,,,facility,both,,,,1293,969.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Flt3/Fms Itd Gene Analysis (Ref Lab),3108124501,CDM,310,RC,81245,HCPCS,,,facility,both,,,,402,301.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Flt3 Gene Analysis (Ref Lab),3108124502,CDM,310,RC,81245,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Glucose-6-Phosphate Dehydrogenase (G6Pd) Full Gene Sequencing, Varies (Ref Lab)",3108124901,CDM,310,RC,81249,HCPCS,,,facility,both,,,,1012,759,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Glucose-6-Phosphate Dehydrogenase (G6Pd) Full Gene Sequencing, Varies (Ref Lab)",3108124901,CDM,310,RC,81249,HCPCS,,,facility,both,,,,1012,759,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Alpha Globin Gene Sequencing,B (Ref Lab)",3108125901,CDM,310,RC,81259,HCPCS,,,facility,both,,,,1138,853.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Alpha Globin Gene Sequencing,B (Ref Lab)",3108125901,CDM,310,RC,81259,HCPCS,,,facility,both,,,,880,660,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomics: Igh Clonality/Mrd By Ngs,3108126303,CDM,310,RC,81263,HCPCS,,,facility,both,,,,528,396,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Comp Analysis Using Str (Ref Lab),3108126501,CDM,310,RC,81265,HCPCS,,,facility,both,,,,534,400.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Add'l Comp Analysis With Str (Ref Lab,3108126601,CDM,310,RC,81266,HCPCS,,,facility,both,,,,578,433.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Sort1-Chimerism W/Comp To Baseline W/Cell Selection Ea,3108126801,CDM,310,RC,81268,HCPCS,,,facility,both,,,,623,467.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Sort1-Chimerism W/Comp To Baseline W/Cell Selection Ea,3108126801,CDM,310,RC,81268,HCPCS,,,facility,both,,,,623,467.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomics: Jak2 Gene Analysis P.Val617Phe Variant,3108127001,CDM,310,RC,81270,HCPCS,,,facility,both,,,,466,349.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Jak2 Gene Analysis P.Val617Phe Variant,3108127001,CDM,310,RC,81270,HCPCS,,,facility,both,,,,466,349.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kit Gene Targeted Seq Analys (Ref Lab),3108127201,CDM,310,RC,81272,HCPCS,,,facility,both,,,,626,469.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kit Gene Targeted Seq Analys (Ref Lab),3108127201,CDM,310,RC,81272,HCPCS,,,facility,both,,,,529,396.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kras Gene Variants Exon 2 (Ref Lab),3108127501,CDM,310,RC,81275,HCPCS,,,facility,both,,,,334,250.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kras Mutation Analysis (Ref Lab),3108127502,CDM,310,RC,81275,HCPCS,,,facility,both,,,,377,282.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kras Gene Addl Variants 1 (Ref Lab),3108127601,CDM,310,RC,81276,HCPCS,,,facility,both,,,,334,250.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kras Gene Addl Variants 2 (Ref Lab),3108127602,CDM,310,RC,81276,HCPCS,,,facility,both,,,,334,250.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kras Exons 3,4 Mutation (Ref Lab)",3108127603,CDM,310,RC,81276,HCPCS,,,facility,both,,,,377,282.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Jak2 V617F W/Reflex To Exon 12-13 Moljak2Ex,3108127901,CDM,310,RC,81279,HCPCS,,,facility,both,,,,466,349.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Jak2 V617F W/Reflex To Exon 12-13 Moljak2Ex,3108127901,CDM,310,RC,81279,HCPCS,,,facility,both,,,,466,349.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Afxn - Fxn (Frataxin) (Eg, Friedreich Ataxia) Gene Analysis; Evaluation To Detect Abnormal (",3108128401,CDM,310,RC,81284,HCPCS,,,facility,both,,,,1011,758.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Afxn - Fxn (Frataxin) (Eg, Friedreich Ataxia) Gene Analysis; Evaluation To Detect Abnormal (",3108128401,CDM,310,RC,81284,HCPCS,,,facility,both,,,,1011,758.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arup/Incyte - Mgmt (O-6-Methylguanine-Dna Methyltransferase) (Eg, Glioblastoma Multiforme) Promot",3108128701,CDM,310,RC,81287,HCPCS,,,facility,both,,,,417,312.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arup/Incyte - Mgmt (O-6-Methylguanine-Dna Methyltransferase) (Eg, Glioblastoma Multiforme) Promot",3108128701,CDM,310,RC,81287,HCPCS,,,facility,both,,,,417,312.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenom -Mlh1 Promoter Methyl (Ref Lab),3108128801,CDM,310,RC,81288,HCPCS,,,facility,both,,,,455,341.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non Mayo-Neogenomics: Microsatellite Instability Analysis,3108130101,CDM,310,RC,81301,HCPCS,,,facility,both,,,,654,490.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non Mayo-Neogenomics: Microsatellite Instability Analysis,3108130101,CDM,310,RC,81301,HCPCS,,,facility,both,,,,654,490.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogen/Myd88 Mutation Analysis (Ref Lab),3108130501,CDM,310,RC,81305,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Myd88-Myd88 L265P Gene Mutation Analysis,3108130502,CDM,310,RC,81305,HCPCS,,,facility,both,,,,688,516,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Myd88-Myd88 L265P Gene Mutation Analysis,3108130502,CDM,310,RC,81305,HCPCS,,,facility,both,,,,620,465,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Npm1 Gene Analysis (Ref Lab),3108131001,CDM,310,RC,81310,HCPCS,,,facility,both,,,,426,319.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Npm1 Gene, Hematologics (Ref Lab)",3108131002,CDM,310,RC,81310,HCPCS,,,facility,both,,,,426,319.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Npm1 Mrd Analysis,3108131003,CDM,310,RC,81310,HCPCS,,,facility,both,,,,475,356.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomics: Npm1 Mrd Analysis,3108131003,CDM,310,RC,81310,HCPCS,,,facility,both,,,,509,381.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nras Gene Analysis (Ref Lab),3108131101,CDM,310,RC,81311,HCPCS,,,facility,both,,,,511,383.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nras Mutation Analysis (Ref Lab),3108131102,CDM,310,RC,81311,HCPCS,,,facility,both,,,,565,423.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw127-Gene Analysis (Poly[A] Binding Protein Nuclear 1) For Abnormal Alleles,3108131201,CDM,310,RC,81312,HCPCS,,,facility,both,,,,810,607.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw127-Gene Analysis (Poly[A] Binding Protein Nuclear 1) For Abnormal Alleles,3108131201,CDM,310,RC,81312,HCPCS,,,facility,both,,,,810,607.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rencp-Pten (Phosphatase And Tensin Homolog) (Eg, Cowden Syndrome, Pten Hamartoma Tumor S",3108132101,CDM,310,RC,81321,HCPCS,,,facility,both,,,,1309,981.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rencp-Pten (Phosphatase And Tensin Homolog) (Eg, Cowden Syndrome, Pten Hamartoma Tumor S",3108132101,CDM,310,RC,81321,HCPCS,,,facility,both,,,,462,346.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Pten Gene Analysis Full Sequence Analysis,3108132102,CDM,310,RC,81321,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Pten Gene Analysis Full Sequence Analysis,3108132102,CDM,310,RC,81321,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Csfp-Smn1 Gene Analysis Dosage/Delet Alys W/Smn2 Alys,3108132901,CDM,310,RC,81329,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Csfp-Smn1 Gene Analysis Dosage/Delet Alys W/Smn2 Alys,3108132901,CDM,310,RC,81329,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mpl Exon 10 Mutation Detection, Reflex, Varies (Ref Lab)",3108133901,CDM,310,RC,81339,HCPCS,,,facility,both,,,,515,386.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Mpl Mutation Analysis,3108133902,CDM,310,RC,81339,HCPCS,,,facility,both,,,,294,220.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Mpl Mutation Analysis,3108133902,CDM,310,RC,81339,HCPCS,,,facility,both,,,,294,220.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogen/T-Cel Receptr Gama Gene (Ref Lab),3108134201,CDM,310,RC,81342,HCPCS,,,facility,both,,,,430,322.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Tert Promoter Mutation Analysis,3108134502,CDM,310,RC,81345,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Tert Promoter Mutation Analysis,3108134502,CDM,310,RC,81345,HCPCS,,,facility,both,,,,405,303.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Sf3B1 Mutation Analysis,3108134701,CDM,310,RC,81347,HCPCS,,,facility,both,,,,396,297,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Sf3B1 Mutation Analysis,3108134701,CDM,310,RC,81347,HCPCS,,,facility,both,,,,396,297,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rencp-Tp53 (Tumor Protein 53) (Eg, Li-Fraumeni Syndrome) Gene Analysis; Full Gene Sequen",3108135101,CDM,310,RC,81351,HCPCS,,,facility,both,,,,934,700.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rencp-Tp53 (Tumor Protein 53) (Eg, Li-Fraumeni Syndrome) Gene Analysis; Full Gene Sequen",3108135101,CDM,310,RC,81351,HCPCS,,,facility,both,,,,934,700.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Tp53 Gene Analysis Full Gene Sequence,3108135102,CDM,310,RC,81351,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Tp53 Gene Analysis Full Gene Sequence,3108135102,CDM,310,RC,81351,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomics: Gene Analysis (Tumor Protein 53) Targeted Sequence Analysis,3108135201,CDM,310,RC,81352,HCPCS,,,facility,both,,,,1012,759,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomics: Gene Analysis (Tumor Protein 53) Targeted Sequence Analysis,3108135201,CDM,310,RC,81352,HCPCS,,,facility,both,,,,1012,759,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Beta Globin Clustr Loc Del/Dup (Ref Lab),3108136301,CDM,310,RC,81363,HCPCS,,,facility,both,,,,624,468,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Beta Globin Clustr Loc Del/Dup (Ref Lab),3108136301,CDM,310,RC,81363,HCPCS,,,facility,both,,,,659,494.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Beta Globin Gene Sequencing, B",3108136401,CDM,310,RC,81364,HCPCS,,,facility,both,,,,1019,764.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Beta Globin Gene Sequencing, B",3108136401,CDM,310,RC,81364,HCPCS,,,facility,both,,,,880,660,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hla-A Low Resolution (Ref Lab),3108137301,CDM,310,RC,81373,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Zw121-Hla Class I Typing, Low Resolution One Antigen Equivalent",3108137401,CDM,310,RC,81374,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Zw121-Hla Class I Typing, Low Resolution One Antigen Equivalent",3108137401,CDM,310,RC,81374,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup: Hla I Low Resolution One Antigen Equivalent Each,3108137402,CDM,310,RC,81374,HCPCS,,,facility,both,,,,247,185.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup: Hla I Low Resolution One Antigen Equivalent Each,3108137402,CDM,310,RC,81374,HCPCS,,,facility,both,,,,247,185.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Cdgf-Celiac Disease Gluten-Free Cascade, Serum And Whole Blood",3108137607,CDM,310,RC,81376,HCPCS,,,facility,both,,,,327,245.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Cdgf-Celiac Disease Gluten-Free Cascade, Serum And Whole Blood",3108137607,CDM,310,RC,81376,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fpaig Pai-1 Gene Polymorphism,3108140001,CDM,310,RC,81400,HCPCS,,,facility,both,,,,532,399,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fpaig Pai-1 Gene Polymorphism,3108140001,CDM,310,RC,81400,HCPCS,,,facility,both,,,,532,399,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Apoeg-Molecular Pathology Procedure Level 2,3108140101,CDM,310,RC,81401,HCPCS,,,facility,both,,,,309,231.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Apoeg-Molecular Pathology Procedure Level 2,3108140101,CDM,310,RC,81401,HCPCS,,,facility,both,,,,309,231.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo In16Q-Cbfb-Myh11 Inversion(16), Quantitative Detection And Minimal Disease Risk Monitoring,",3108140102,CDM,310,RC,81401,HCPCS,,,facility,both,,,,1079,809.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo _G130-Known Familial Variant,Other",3108140301,CDM,310,RC,81403,HCPCS,,,facility,both,,,,551,413.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo _G130-Known Familial Variant,Other",3108140301,CDM,310,RC,81403,HCPCS,,,facility,both,,,,551,413.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Fmtt-Molecular Pathology Procedure Level 4,3108140302,CDM,310,RC,81403,HCPCS,,,facility,both,,,,551,413.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw242-Molecular Pathology Procedure Level 4,3108140303,CDM,310,RC,81403,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 4,3108140304,CDM,310,RC,81403,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 4,3108140304,CDM,310,RC,81403,HCPCS,,,facility,both,,,,129,96.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 4,3108140305,CDM,310,RC,81403,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 4,3108140305,CDM,310,RC,81403,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ymcro-Y Microdeletion,3108140306,CDM,310,RC,81403,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ymcro-Y Microdeletion,3108140306,CDM,310,RC,81403,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 4,3108140307,CDM,310,RC,81403,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 4,3108140307,CDM,310,RC,81403,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Lqtsg-Molecular Pathology Procedure Level 4,3108140308,CDM,310,RC,81403,HCPCS,,,facility,both,,,,370,277.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Lqtsg-Molecular Pathology Procedure Level 4,3108140308,CDM,310,RC,81403,HCPCS,,,facility,both,,,,370,277.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Molecular Path Level 5 Addl (Ref Lab),3108140401,CDM,310,RC,81404,HCPCS,,,facility,both,,,,876,657,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Rencp-Full Gene Sequence Actn4,3108140402,CDM,310,RC,81404,HCPCS,,,facility,both,,,,629,471.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Rencp-Full Gene Sequence Actn4,3108140402,CDM,310,RC,81404,HCPCS,,,facility,both,,,,629,471.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cgph-Molecular Pathology Procedure Level 5,3108140403,CDM,310,RC,81404,HCPCS,,,facility,both,,,,1898,1423.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cgph-Molecular Pathology Procedure Level 5,3108140403,CDM,310,RC,81404,HCPCS,,,facility,both,,,,1898,1423.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw242-Molecular Pathology Procedure Level 5,3108140404,CDM,310,RC,81404,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 5,3108140405,CDM,310,RC,81404,HCPCS,,,facility,both,,,,191,143.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 5,3108140405,CDM,310,RC,81404,HCPCS,,,facility,both,,,,191,143.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 5,3108140406,CDM,310,RC,81404,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 5,3108140406,CDM,310,RC,81404,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hpanp-Molecular Pathology Procedure Level 5,3108140407,CDM,310,RC,81404,HCPCS,,,facility,both,,,,712,534,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 5,3108140408,CDM,310,RC,81404,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 5,3108140408,CDM,310,RC,81404,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rencp-Hereditary Renal Cancer Panel, Varies",3108140501,CDM,310,RC,81405,HCPCS,,,facility,both,,,,658,493.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rencp-Hereditary Renal Cancer Panel, Varies",3108140501,CDM,310,RC,81405,HCPCS,,,facility,both,,,,658,493.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Xaldz-X-Ald, Full Gene Analysis",3108140502,CDM,310,RC,81405,HCPCS,,,facility,both,,,,1566,1174.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Xaldz-X-Ald, Full Gene Analysis",3108140502,CDM,310,RC,81405,HCPCS,,,facility,both,,,,1566,1174.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Stat3 Mutation Analysis,3108140503,CDM,310,RC,81405,HCPCS,,,facility,both,,,,713,534.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Adpkp-Focused Adpkd Gene Panel Level 6,3108140504,CDM,310,RC,81405,HCPCS,,,facility,both,,,,593,444.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Adpkp-Focused Adpkd Gene Panel Level 6,3108140504,CDM,310,RC,81405,HCPCS,,,facility,both,,,,593,444.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Molecular Pathology Procedure Level 6 Genetic Analysis,3108140505,CDM,310,RC,81405,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 6,3108140506,CDM,310,RC,81405,HCPCS,,,facility,both,,,,294,220.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 6,3108140506,CDM,310,RC,81405,HCPCS,,,facility,both,,,,294,220.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 6,3108140507,CDM,310,RC,81405,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 6,3108140507,CDM,310,RC,81405,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hpanp-Molecular Pathology Procedure Level 6,3108140508,CDM,310,RC,81405,HCPCS,,,facility,both,,,,781,585.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 6,3108140509,CDM,310,RC,81405,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 6,3108140509,CDM,310,RC,81405,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Notch3 (Cadasil) Sequence Test (Ref Lab),3108140601,CDM,310,RC,81406,HCPCS,,,facility,both,,,,3195,2396.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Notch3 (Cadasil) Sequence Test (Ref Lab),3108140601,CDM,310,RC,81406,HCPCS,,,facility,both,,,,3194,2395.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Molecular Path Level 7 Initial (Ref Lab),3108140602,CDM,310,RC,81406,HCPCS,,,facility,both,,,,876,657,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Wilson Disease Full Gene Anlys (Ref Lab),3108140603,CDM,310,RC,81406,HCPCS,,,facility,both,,,,3304,2478,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Wilson Disease Full Gene Anlys (Ref Lab),3108140603,CDM,310,RC,81406,HCPCS,,,facility,both,,,,2045,1533.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rencp-Molecular Pathology Procedure, Level 7",3108140604,CDM,310,RC,81406,HCPCS,,,facility,both,,,,618,463.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rencp-Molecular Pathology Procedure, Level 7",3108140604,CDM,310,RC,81406,HCPCS,,,facility,both,,,,618,463.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fhrgp-Molecular Pathology Procedure Level 7,3108140605,CDM,310,RC,81406,HCPCS,,,facility,both,,,,1457,1092.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fhrgp-Molecular Pathology Procedure Level 7,3108140605,CDM,310,RC,81406,HCPCS,,,facility,both,,,,1457,1092.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Hchlg-Molecular Pathology Procedure Level 7,3108140606,CDM,310,RC,81406,HCPCS,,,facility,both,,,,1457,1092.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Hchlg-Molecular Pathology Procedure Level 7,3108140606,CDM,310,RC,81406,HCPCS,,,facility,both,,,,1457,1092.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Smat-Molecular Pathology Procedure Level 7,3108140607,CDM,310,RC,81406,HCPCS,,,facility,both,,,,583,437.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Smat-Molecular Pathology Procedure Level 7,3108140607,CDM,310,RC,81406,HCPCS,,,facility,both,,,,583,437.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Adpkp -Focused Adpkd Gene Panel Level 7,3108140608,CDM,310,RC,81406,HCPCS,,,facility,both,,,,557,417.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Adpkp -Focused Adpkd Gene Panel Level 7,3108140608,CDM,310,RC,81406,HCPCS,,,facility,both,,,,557,417.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw242-Molecular Pathology Procedure Level 7,3108140609,CDM,310,RC,81406,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Tscp -Molecular Pathology Procedure Level 7,3108140610,CDM,310,RC,81406,HCPCS,,,facility,both,,,,507,380.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 7,3108140611,CDM,310,RC,81406,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 7,3108140611,CDM,310,RC,81406,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 7,3108140612,CDM,310,RC,81406,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 7,3108140612,CDM,310,RC,81406,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 7,3108140613,CDM,310,RC,81406,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 7,3108140613,CDM,310,RC,81406,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Lqtsg-Molecular Pathology Procedure Level 7,3108140614,CDM,310,RC,81406,HCPCS,,,facility,both,,,,565,423.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Lqtsg-Molecular Pathology Procedure Level 7,3108140614,CDM,310,RC,81406,HCPCS,,,facility,both,,,,565,423.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Rencp-Molecular Pathology Procedure, Level 8",3108140701,CDM,310,RC,81407,HCPCS,,,facility,both,,,,1846,1384.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Rencp-Molecular Pathology Procedure, Level 8",3108140701,CDM,310,RC,81407,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fhrgp-Molecular Pathology Procedure Level 8,3108140702,CDM,310,RC,81407,HCPCS,,,facility,both,,,,2180,1635,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fhrgp-Molecular Pathology Procedure Level 8,3108140702,CDM,310,RC,81407,HCPCS,,,facility,both,,,,1896,1422,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Hchlg-Molecular Pathology Procedure Level 8,3108140703,CDM,310,RC,81407,HCPCS,,,facility,both,,,,2180,1635,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Hchlg-Molecular Pathology Procedure Level 8,3108140703,CDM,310,RC,81407,HCPCS,,,facility,both,,,,1896,1422,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Tscp-Molecular Pathology Procedure Level 8,3108140704,CDM,310,RC,81407,HCPCS,,,facility,both,,,,1743,1307.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Tscp-Molecular Pathology Procedure Level 8,3108140704,CDM,310,RC,81407,HCPCS,,,facility,both,,,,1516,1137,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Adpkp -Focused Adpkd Gene Panel Levvel 8,3108140705,CDM,310,RC,81407,HCPCS,,,facility,both,,,,1664,1248,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Adpkp -Focused Adpkd Gene Panel Levvel 8,3108140705,CDM,310,RC,81407,HCPCS,,,facility,both,,,,1664,1248,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 8,3108140706,CDM,310,RC,81407,HCPCS,,,facility,both,,,,588,441,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Molecular Pathology Procedure Level 8,3108140706,CDM,310,RC,81407,HCPCS,,,facility,both,,,,588,441,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Lqtsg-Molecular Pathology Procedure Level 8,3108140707,CDM,310,RC,81407,HCPCS,,,facility,both,,,,1689,1266.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Lqtsg-Molecular Pathology Procedure Level 8,3108140707,CDM,310,RC,81407,HCPCS,,,facility,both,,,,1689,1266.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mopath Procedure Level 9 #1 (Ref Lab),3108140801,CDM,310,RC,81408,HCPCS,,,facility,both,,,,2300,1725,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mopath Procedure Level 9 #2 (Ref Lab),3108140802,CDM,310,RC,81408,HCPCS,,,facility,both,,,,2300,1725,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Zw242-Molecular Pathology Procedure Level 9,3108140803,CDM,310,RC,81408,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 9,3108140804,CDM,310,RC,81408,HCPCS,,,facility,both,,,,737,552.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Comcp-Molecular Pathology Procedure Level 9,3108140804,CDM,310,RC,81408,HCPCS,,,facility,both,,,,737,552.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 9,3108140805,CDM,310,RC,81408,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup-Molecular Pathology Procedure Level 9,3108140805,CDM,310,RC,81408,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Brgyp-Hereditary Breast/Gynecologic Cancer Panel, Varies",3108143201,CDM,310,RC,81432,HCPCS,,,facility,both,,,,2776,2082,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Brgyp-Hereditary Breast/Gynecologic Cancer Panel, Varies",3108143201,CDM,310,RC,81432,HCPCS,,,facility,both,,,,2414,1810.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Endcp-Gene Analysis (Neuroendocrine Tumors), Genomic Sequence",3108143701,CDM,310,RC,81437,HCPCS,,,facility,both,,,,4042,3031.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Endcp-Gene Analysis (Neuroendocrine Tumors), Genomic Sequence",3108143701,CDM,310,RC,81437,HCPCS,,,facility,both,,,,4042,3031.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hemophagocytic Lymphohist Gene (Ref Lab),3108144301,CDM,310,RC,81443,HCPCS,,,facility,both,,,,4853,3639.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Genetic Tstg Severe Inh Cond (Ref Lab),3108144302,CDM,310,RC,81443,HCPCS,,,facility,both,,,,3097,2322.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Severe Immuno Pnl (63) Ng Seq (Ref Lab),3108144303,CDM,310,RC,81443,HCPCS,,,facility,both,,,,4265,3198.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Severe Immuno Pnl (63) Ng Seq (Ref Lab),3108144303,CDM,310,RC,81443,HCPCS,,,facility,both,,,,4265,3198.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Teldp-Genetic Testing For Severe Inherited Conditions,3108144304,CDM,310,RC,81443,HCPCS,,,facility,both,,,,2846,2134.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cmsp-Genetic Testing For Severe Inherited Conditions,3108144305,CDM,310,RC,81443,HCPCS,,,facility,both,,,,2910,2182.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cmsp-Genetic Testing For Severe Inherited Conditions,3108144305,CDM,310,RC,81443,HCPCS,,,facility,both,,,,2910,2182.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan Peripheral Neuropathy Expanded Panel G103,3108144801,CDM,310,RC,81448,HCPCS,,,facility,both,,,,3819,2864.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan Peripheral Neuropathy Expanded Panel G103,3108144801,CDM,310,RC,81448,HCPCS,,,facility,both,,,,3321,2490.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan  Motor And Sensory Neuropathy Panel G104,3108144802,CDM,310,RC,81448,HCPCS,,,facility,both,,,,3200,2400,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan  Motor And Sensory Neuropathy Panel G104,3108144802,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2783,2087.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan Hereditary Sensory Neuropathy Panel G105,3108144803,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2619,1964.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan Hereditary Sensory Neuropathy Panel G105,3108144803,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2277,1707.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan Hereditary Motor Neuropathy Panel G106,3108144804,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2765,2073.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan Hereditary Motor Neuropathy Panel G106,3108144804,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2404,1803,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan Spastic Paraplegia Neuropathy Panel G107,3108144805,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2765,2073.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan Spastic Paraplegia Neuropathy Panel G107,3108144805,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2404,1803,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan Metabolic Or Syndromic Neuropathies G108,3108144806,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2982,2236.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan Metabolic Or Syndromic Neuropathies G108,3108144806,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2593,1944.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan Custom Gene Panel(Cpt 81448) Tier 2 G151,3108144807,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2309,1731.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan Custom Gene Panel(Cpt 81448) Tier 2 G151,3108144807,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2008,1506,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan Custom Gene Panel(Cpt 81448) Tier 3 G152,3108144808,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2924,2193,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan Custom Gene Panel(Cpt 81448) Tier 3 G152,3108144808,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2543,1907.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan Custom Gene Panel(Cpt 81448) Tier 4 G153,3108144809,CDM,310,RC,81448,HCPCS,,,facility,both,,,,2944,2208,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Nppan-Nppan Custom Gene Panel(Cpt 81448) Tier 4 G153,3108144809,CDM,310,RC,81448,HCPCS,,,facility,both,,,,3386,2539.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan Custom Gene Panel(Cpt 81448) Tier 5 G154,3108144810,CDM,310,RC,81448,HCPCS,,,facility,both,,,,4463,3347.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Nppan-Nppan Custom Gene Panel(Cpt 81448) Tier 5 G154,3108144810,CDM,310,RC,81448,HCPCS,,,facility,both,,,,3881,2910.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ispp-Gene Analysis Panel For Hereditary Disorders Of The Peripheral Nervous System,3108144811,CDM,310,RC,81448,HCPCS,,,facility,both,,,,3162,2371.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ispp-Gene Analysis Panel For Hereditary Disorders Of The Peripheral Nervous System,3108144811,CDM,310,RC,81448,HCPCS,,,facility,both,,,,3162,2371.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Imsnp-Hereditary Peripheral Neuropathy Gen Seq Pnl,3108144812,CDM,310,RC,81448,HCPCS,,,facility,both,,,,3162,2371.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Targeted Genomic Seq Analys - Genomis (Ref Lab),3108145001,CDM,310,RC,81450,HCPCS,,,facility,both,,,,1311,983.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Targeted Genomic Seq Analys (Ref Lab),3108145002,CDM,310,RC,81450,HCPCS,,,facility,both,,,,1311,983.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Ngshm-Oncoheme Next-Generation Sequencing For Myeloid Neoplasms,3108145003,CDM,310,RC,81450,HCPCS,,,facility,both,,,,3050,2287.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Ngshm-Oncoheme Next-Generation Sequencing For Myeloid Neoplasms,3108145003,CDM,310,RC,81450,HCPCS,,,facility,both,,,,3050,2287.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Myeloid Disorders Profile,3108145004,CDM,310,RC,81450,HCPCS,,,facility,both,,,,3782,2836.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Myeloid Disorders Profile,3108145004,CDM,310,RC,81450,HCPCS,,,facility,both,,,,3289,2466.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Neotype Mds/Cmml Profile,3108145005,CDM,310,RC,81450,HCPCS,,,facility,both,,,,3188,2391,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Neotype Mds/Cmml Profile,3108145005,CDM,310,RC,81450,HCPCS,,,facility,both,,,,3233,2424.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Neotype Aml Prognostic Profile,3108145006,CDM,310,RC,81450,HCPCS,,,facility,both,,,,2328,1746,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Neotype Aml Prognostic Profile,3108145006,CDM,310,RC,81450,HCPCS,,,facility,both,,,,2328,1746,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomics: Hematolymphoid Neo/Do Gsap 5-50Dna/Dna&Rna Alys,3108145007,CDM,310,RC,81450,HCPCS,,,facility,both,,,,4896,3672,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Hematolymphoid Neo/Do Gsap 5-50Dna/Dna&Rna Alys,3108145007,CDM,310,RC,81450,HCPCS,,,facility,both,,,,4896,3672,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Myd-88 Mutation Analysis (Ref Lab),3108147901,CDM,310,RC,81479,HCPCS,,,facility,both,,,,611,458.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Myd-88 Mutation Analysis (Ref Lab),3108147901,CDM,310,RC,81479,HCPCS,,,facility,both,,,,611,458.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc H2-Hematologic Malig Genomic (Ref Lab),3108147902,CDM,310,RC,81479,HCPCS,,,facility,both,,,,4428,3321,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc H2-Hematologic Malig Genomic (Ref Lab),3108147902,CDM,310,RC,81479,HCPCS,,,facility,both,,,,4428,3321,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Hereditary Erythrocyto Mut, B (Ref Lab)",3108147903,CDM,310,RC,81479,HCPCS,,,facility,both,,,,864,648,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bpgm Full Gene Sequencing (Ref Lab),3108147904,CDM,310,RC,81479,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hemophagocytic Lymp Stx11 Fhl4 (Ref Lab),3108147905,CDM,310,RC,81479,HCPCS,,,facility,both,,,,800,600,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Extracted Molecular Procedure (Ref Lab),3108147906,CDM,310,RC,81479,HCPCS,,,facility,both,,,,151,113.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hemophagocytic L Fhl2 Perforin (Ref Lab),3108147907,CDM,310,RC,81479,HCPCS,,,facility,both,,,,994,745.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phagocytic Pid Gene Panel (Ref Lab),3108147908,CDM,310,RC,81479,HCPCS,,,facility,both,,,,3162,2371.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Psychotropic - Pgx (Ref Lab),3108147909,CDM,310,RC,81479,HCPCS,,,facility,both,,,,611,458.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomic-Srsf2 Mutation Anal (Ref Lab),3108147910,CDM,310,RC,81479,HCPCS,,,facility,both,,,,611,458.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Caris - Zb8N7 (Ref Lab),3108147911,CDM,310,RC,81479,HCPCS,,,facility,both,,,,3694,2770.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Caris - Zb8N7 (Ref Lab),3108147911,CDM,310,RC,81479,HCPCS,,,facility,both,,,,3694,2770.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomic - Ntrk Ngs Fusion (Ref Lab),3108147912,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1012,759,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Unlisted Mopath, A4, Panel (Ref Lab)",3108147913,CDM,310,RC,81479,HCPCS,,,facility,both,,,,876,657,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cell Receptor Exc Circ(Trec) (Ref Lab),3108147914,CDM,310,RC,81479,HCPCS,,,facility,both,,,,611,458.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc T-Cell Receptor Exc Circ(Trec) (Ref Lab),3108147914,CDM,310,RC,81479,HCPCS,,,facility,both,,,,362,271.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc F5 Gene, Next Generation, Seq (Ref Lab)",3108147915,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1898,1423.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ehleris-Danlos Syndrome Gene (Ref Lab),3108147916,CDM,310,RC,81479,HCPCS,,,facility,both,,,,0.01,0.01,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mcadz-Medium-Chain Acyl-Coa Dehydrogenase (Mcad) Deficiency Full Gene Analysis, Varies",3108147920,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1991,1493.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Mcadz-Medium-Chain Acyl-Coa Dehydrogenase (Mcad) Deficiency Full Gene Analysis, Varies",3108147920,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1731,1298.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Telgp-Telomere Defects Gene Panel,3108147921,CDM,310,RC,81479,HCPCS,,,facility,both,,,,3636,2727,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Telgp-Telomere Defects Gene Panel,3108147921,CDM,310,RC,81479,HCPCS,,,facility,both,,,,3162,2371.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Rencp-Unlisted Molecular Pathology Procedure,3108147922,CDM,310,RC,81479,HCPCS,,,facility,both,,,,0.01,0.01,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Rencp-Unlisted Molecular Pathology Procedure,3108147922,CDM,310,RC,81479,HCPCS,,,facility,both,,,,819,614.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Non Mayo-Neogenomics: B-Cell Gene Rearrangement,3108147923,CDM,310,RC,81479,HCPCS,,,facility,both,,,,749,561.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Non Mayo-Neogenomics: B-Cell Gene Rearrangement,3108147923,CDM,310,RC,81479,HCPCS,,,facility,both,,,,557,417.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Cxcr4 Mutation Analysis,3108147924,CDM,310,RC,81479,HCPCS,,,facility,both,,,,819,614.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Cxcr4 Mutation Analysis,3108147924,CDM,310,RC,81479,HCPCS,,,facility,both,,,,493,369.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Idh1/Idh2 Mutation Analysis,3108147925,CDM,310,RC,81479,HCPCS,,,facility,both,,,,435,326.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Idh1/Idh2 Mutation Analysis,3108147925,CDM,310,RC,81479,HCPCS,,,facility,both,,,,749,561.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Nppan-Nppan  Sept9 Gene, Full Gene Analysis G132",3108147926,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1455,1091.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Nppan-Nppan  Sept9 Gene, Full Gene Analysis G132",3108147926,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1265,948.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Non-Mayo-Neogenomics: Kras Mutation Analysis By Sanger, Ex 2-4",3108147927,CDM,310,RC,81479,HCPCS,,,facility,both,,,,727,545.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Non-Mayo-Neogenomics: Kras Mutation Analysis By Sanger, Ex 2-4",3108147927,CDM,310,RC,81479,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Flt3 Mutation (Itd & Tkd) Analysis,3108147928,CDM,310,RC,81479,HCPCS,,,facility,both,,,,475,356.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Flt3 Mutation (Itd & Tkd) Analysis,3108147928,CDM,310,RC,81479,HCPCS,,,facility,both,,,,435,326.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Non-Mayo-Neogenomics: Kras Mutation Analysis By Sanger, Ex 2-4",3108147929,CDM,310,RC,81479,HCPCS,,,facility,both,,,,727,545.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Non-Mayo-Neogenomics: Kras Mutation Analysis By Sanger, Ex 2-4",3108147929,CDM,310,RC,81479,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Ntc3Z Notch3 Gene, Full Gene Analysis",3108147930,CDM,310,RC,81479,HCPCS,,,facility,both,,,,2910,2182.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Ntc3Z Notch3 Gene, Full Gene Analysis",3108147930,CDM,310,RC,81479,HCPCS,,,facility,both,,,,2530,1897.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bhdz Flcn Full Gene Analysis,3108147931,CDM,310,RC,81479,HCPCS,,,facility,both,,,,2024,1518,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Bhdz Flcn Full Gene Analysis,3108147931,CDM,310,RC,81479,HCPCS,,,facility,both,,,,2328,1746,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Nras Mutation Analysis By Sanger,3108147932,CDM,310,RC,81479,HCPCS,,,facility,both,,,,844,633,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Nras Mutation Analysis By Sanger,3108147932,CDM,310,RC,81479,HCPCS,,,facility,both,,,,734,550.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Fhrgp-Hypercholesterolemia Gene Panel,3108147933,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1,0.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Fhrgp-Hypercholesterolemia Gene Panel,3108147933,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1,0.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Hchlg-Hypercholesterolemia Gene Panel,3108147934,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1,0.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Hchlg-Hypercholesterolemia Gene Panel,3108147934,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1,0.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non Mayo-Neogenomics: Neotype Next-Gen Other Solid Tumor Profile,3108147935,CDM,310,RC,81479,HCPCS,,,facility,both,,,,2328,1746,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non Mayo-Neogenomics: Neotype Next-Gen Other Solid Tumor Profile,3108147935,CDM,310,RC,81479,HCPCS,,,facility,both,,,,2024,1518,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Csfp-Carrier Screen, Focused Panel",3108147936,CDM,310,RC,81479,HCPCS,,,facility,both,,,,0.01,0.01,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Csfp-Carrier Screen, Focused Panel",3108147936,CDM,310,RC,81479,HCPCS,,,facility,both,,,,0.01,0.01,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Neotype Dna & Rna--Brain,3108147937,CDM,310,RC,81479,HCPCS,,,facility,both,,,,3162,2371.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Neogenomics: Neotype Dna & Rna--Brain,3108147937,CDM,310,RC,81479,HCPCS,,,facility,both,,,,3636,2727,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Non-Mayo-Neogenomics: Bcr-Abl1 Standard P210, P190 (Major/Minor)",3108147938,CDM,310,RC,81479,HCPCS,,,facility,both,,,,466,349.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Non-Mayo-Neogenomics: Bcr-Abl1 Standard P210, P190 (Major/Minor)",3108147938,CDM,310,RC,81479,HCPCS,,,facility,both,,,,443,332.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Caris: Z01V0,3108147940,CDM,310,RC,81479,HCPCS,,,facility,both,,,,4428,3321,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Caris: Z01V0,3108147940,CDM,310,RC,81479,HCPCS,,,facility,both,,,,4261,3195.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Zw242-Molecular Pathology Procedure,3108147941,CDM,310,RC,81479,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Neo Comprehensive - Molecular Pathology Procedure Myeloid Disorders,3108147942,CDM,310,RC,81479,HCPCS,,,facility,both,,,,5629,4221.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Neo Comprehensive - Molecular Pathology Procedure Myeloid Disorders,3108147942,CDM,310,RC,81479,HCPCS,,,facility,both,,,,5629,4221.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo C9Orf-C9Orf72, Molecular Analysis",3108147943,CDM,310,RC,81479,HCPCS,,,facility,both,,,,629,471.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Neotype Cll Profile,3108147944,CDM,310,RC,81479,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cgph - Unlisted Molecular Pathology:G145: Custom Gene Order Tier 1,3108147945,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1898,1423.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cgph - Unlisted Molecular Pathology:G145: Custom Gene Order Tier 1,3108147945,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1898,1423.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Gnprs-Unlisted Molecular Pathology Procedure: Pros1 Gene, Full Gene Ngs",3108147946,CDM,310,RC,81479,HCPCS,,,facility,both,,,,2021,1515.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Gnprs-Unlisted Molecular Pathology Procedure: Pros1 Gene, Full Gene Ngs",3108147946,CDM,310,RC,81479,HCPCS,,,facility,both,,,,2021,1515.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Arup- Unlisted Molecular Pathology Procedure: (28) Single Gene - Aldh2,3108147947,CDM,310,RC,81479,HCPCS,,,facility,both,,,,336,252,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arup- Unlisted Molecular Pathology Procedure: (28) Single Gene - Aldh2,3108147947,CDM,310,RC,81479,HCPCS,,,facility,both,,,,336,252,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Aftdp-Unlisted Molecular Pathology: Ftd And Als Gene Panel,3108147948,CDM,310,RC,81479,HCPCS,,,facility,both,,,,0.01,0.01,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Aftdp-Unlisted Molecular Pathology: Ftd And Als Gene Panel,3108147948,CDM,310,RC,81479,HCPCS,,,facility,both,,,,0.01,0.01,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Lqtsg- Long Qt Syndrome Gene Panel,3108147950,CDM,310,RC,81479,HCPCS,,,facility,both,,,,0.02,0.02,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Lqtsg- Long Qt Syndrome Gene Panel,3108147950,CDM,310,RC,81479,HCPCS,,,facility,both,,,,0.02,0.02,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Esr1-Mutations Analysis, Tumor",3108147951,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1594,1195.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Esr1-Mutations Analysis, Tumor",3108147951,CDM,310,RC,81479,HCPCS,,,facility,both,,,,1594,1195.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Neotype Mds/Cmml Profile,3108154002,CDM,310,RC,81540,HCPCS,,,facility,both,,,,8183,6137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Neotype Mds/Cmml Profile,3108154002,CDM,310,RC,81540,HCPCS,,,facility,both,,,,3036,2277,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Necropsy (Autopsy)-Gross And Microscopic; Without Cns,3108802001,CDM,310,RC,88020,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Necropsy (Autopsy)-Gross And Microscopic; Without Cns,3108802001,CDM,310,RC,88020,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Necropsy Gross & Microscopic W/Brain,3108802501,CDM,310,RC,88025,HCPCS,,,facility,both,,,,2200,1650,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Necropsy Gross & Microscopic W/Brain,3108802501,CDM,310,RC,88025,HCPCS,,,facility,both,,,,2200,1650,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Necropsy (Autopsy)-Gross And Microscopic; With Brain And Spinal Cord,3108802701,CDM,310,RC,88027,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Necropsy (Autopsy)-Gross And Microscopic; With Brain And Spinal Cord,3108802701,CDM,310,RC,88027,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Necropsy (Autopsy)-Gross And Microscopic; Infant With Brain,3108802801,CDM,310,RC,88028,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Necropsy (Autopsy)-Gross And Microscopic; Infant With Brain,3108802801,CDM,310,RC,88028,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Necropsy (Autopsy)-Gross And Microscopic; Stillborn Or Newborn With Brain,3108802901,CDM,310,RC,88029,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Necropsy (Autopsy)-Gross And Microscopic; Stillborn Or Newborn With Brain,3108802901,CDM,310,RC,88029,HCPCS,,,facility,both,,,,314,235.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cytogenetics,T.Cult,Neoplastic (Ref Lab)",3108823701,CDM,310,RC,88237,HCPCS,,,facility,both,,,,505,378.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Addt'l Tissue Culture Bone Marrow/Blood,3108823703,CDM,310,RC,88237,HCPCS,,,facility,both,,,,340,255,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Addt'l Tissue Culture Bone Marrow/Blood,3108823703,CDM,310,RC,88237,HCPCS,,,facility,both,,,,340,255,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Cytogen,Analyze 5 Cells (Hmt) (Ref Lab)",3108826101,CDM,310,RC,88261,HCPCS,,,facility,both,,,,457,342.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cytogen,Analy 20-25 Cells(Hmt) (Ref Lab)",3108826401,CDM,310,RC,88264,HCPCS,,,facility,both,,,,437,327.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo _I099-Molecular Cytogenetics Interphase Ish 25-99 Cll,3108827401,CDM,310,RC,88274,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo _I099-Molecular Cytogenetics Interphase Ish 25-99 Cll,3108827401,CDM,310,RC,88274,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Chromosome Analysis, Congenital Disorders, Blood (Ref Lab)",3108829101,CDM,310,RC,88291,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Chromosome Analysis, Congenital Disorders, Blood (Ref Lab)",3108829101,CDM,310,RC,88291,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nadf Cyto/Molecular Report,3108829102,CDM,310,RC,88291,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nadf Cyto/Molecular Report,3108829102,CDM,310,RC,88291,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Clldf-Chronic Lymphocytic Leukemia, Diagnostic Fish, Varies",3108829104,CDM,310,RC,88291,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Clldf-Chronic Lymphocytic Leukemia, Diagnostic Fish, Varies",3108829104,CDM,310,RC,88291,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Cytogenetics Interpretation And Report,3108829105,CDM,310,RC,88291,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Non Mayo-Neogenomics: Cytogenetics Interpretation And Report,3108829105,CDM,310,RC,88291,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Eosdf-Chronic Eosinophilia, Diagnostic Fish",3108829106,CDM,310,RC,88291,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Eosdf-Chronic Eosinophilia, Diagnostic Fish",3108829106,CDM,310,RC,88291,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Dd22F- Cytogenetics And Molecular Cytogenetics, Interpretation And Report",3108829107,CDM,310,RC,88291,HCPCS,,,facility,both,,,,206,154.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Dd22F- Cytogenetics And Molecular Cytogenetics, Interpretation And Report",3108829107,CDM,310,RC,88291,HCPCS,,,facility,both,,,,179,134.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cllmf-Interpretation And Report Of Genetic Testing,3108829108,CDM,310,RC,88291,HCPCS,,,facility,both,,,,115,86.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cllmf-Interpretation And Report Of Genetic Testing,3108829108,CDM,310,RC,88291,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Mamlf-Cytogenetics And Molecular Cytogenetics, Interpretation And Report",3108829109,CDM,310,RC,88291,HCPCS,,,facility,both,,,,413,309.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Mamlf-Cytogenetics And Molecular Cytogenetics, Interpretation And Report",3108829109,CDM,310,RC,88291,HCPCS,,,facility,both,,,,359,269.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mdm2F-Cytogenetics&Molec Cytogenetics Interp&Rep,3108829110,CDM,310,RC,88291,HCPCS,,,facility,both,,,,388,291,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Mdm2F-Cytogenetics&Molec Cytogenetics Interp&Rep,3108829110,CDM,310,RC,88291,HCPCS,,,facility,both,,,,388,291,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Tlblf-Cytogenetics&Molec Cytogenetics Interp&Rep,3108829111,CDM,310,RC,88291,HCPCS,,,facility,both,,,,500,375,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Tlblf-Cytogenetics&Molec Cytogenetics Interp&Rep,3108829111,CDM,310,RC,88291,HCPCS,,,facility,both,,,,500,375,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Hemmf-Cytogenetics And Molecular Cytogenetics, Interpretation And Report",3108829112,CDM,310,RC,88291,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Hemmf-Cytogenetics And Molecular Cytogenetics, Interpretation And Report",3108829112,CDM,310,RC,88291,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Surg Level Iv Tc (Outside Ref Lab),3108830501,CDM,310,RC,88305,HCPCS,,,facility,both,,,,321,240.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histo Surg Path Decal (Ref Lab),3108831101,CDM,310,RC,88311,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Histo Surg Path Decal (Ref Lab),3108831101,CDM,310,RC,88311,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Decalcification Procedure,3108831102,CDM,310,RC,88311,HCPCS,,,facility,both,,,,47,35.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Histo/Cyto Stain Ss.1 (Ref Lab),3108831202,CDM,310,RC,88312,HCPCS,,,facility,both,,,,215,161.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bwpo Lab - Microslide Consult (Ref Lab),3108831203,CDM,310,RC,88312,HCPCS,,,facility,both,,,,443,332.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: Special Tissue Stain-Tc,3108831204,CDM,310,RC,88312,HCPCS,,,facility,both,,,,99,74.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histo/Cyto Stain Ss.2 (Ref Lab),3108831302,CDM,310,RC,88313,HCPCS,,,facility,both,,,,218,163.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Surg Ss Group Ii Tc (Outside Ref Lab),3108831303,CDM,310,RC,88313,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ampip-Special Stained Specimen Slides To Examine Tissue Including Interpretation And Report,3108831304,CDM,310,RC,88313,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ampip-Special Stained Specimen Slides To Examine Tissue Including Interpretation And Report,3108831304,CDM,310,RC,88313,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histochemicl Stain (Ref Lab),3108831401,CDM,310,RC,88314,HCPCS,,,facility,both,,,,501,375.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arkana: Special Stain Including Interpretation And Report; Histochemical Stain On Frozen Tissue B,3108831402,CDM,310,RC,88314,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arkana: Special Stain I&R Group Iii Enzyme Consituents,3108831901,CDM,310,RC,88319,HCPCS,,,facility,both,,,,155,116.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Consult, Outside Slide (Ref Lab)",3108832101,CDM,310,RC,88321,HCPCS,,,facility,both,,,,229,171.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arkana: Consultation And Report On Referred Slides Prepared Elsewhere,3108832102,CDM,310,RC,88321,HCPCS,,,facility,both,,,,192,144,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cospc - Consultation And Report On Referred Slides Prepared Elsewhere,3108832103,CDM,310,RC,88321,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cospc - Consultation And Report On Referred Slides Prepared Elsewhere,3108832103,CDM,310,RC,88321,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Crhpc-Consult, W/Comp Rvw Of History",3108832501,CDM,310,RC,88325,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Crhpc-Consult, W/Comp Rvw Of History",3108832501,CDM,310,RC,88325,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Crhpc-Consultation, Comprehensive, With Review Of Records And Specimens, With Report On Refe",3108832502,CDM,310,RC,88325,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Crhpc-Consultation, Comprehensive, With Review Of Records And Specimens, With Report On Refe",3108832502,CDM,310,RC,88325,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Path Consult Intraop 1 Bloc,3108833101,CDM,310,RC,88331,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Histo Surg Path Frozen, First  (Ref Lab)",3108833102,CDM,310,RC,88331,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Path Consult Intraop Addl,3108833201,CDM,310,RC,88332,HCPCS,,,facility,both,,,,118,88.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Path Consult Intraop Addl,3108833201,CDM,310,RC,88332,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Histo Surg Path Frozen, Add (Ref Lab)",3108833202,CDM,310,RC,88332,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Histo Or Touch Prep, Initial (Ref Lab)",3108833301,CDM,310,RC,88333,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Histo Or Touch Prep,Additional (Ref Lab)",3108833401,CDM,310,RC,88334,HCPCS,,,facility,both,,,,49,36.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunohisto Antibody Slide,3108834101,CDM,310,RC,88341,HCPCS,,,facility,both,,,,207,155.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunohisto Antibody Slide,3108834101,CDM,310,RC,88341,HCPCS,,,facility,both,,,,207,155.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Ihc Antibody Stain Additional  (Ref Lab),3108834102,CDM,310,RC,88341,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Growth Hormone (Ref Lab),3108834103,CDM,310,RC,88341,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc  Msh2 (Ref Lab),3108834104,CDM,310,RC,88341,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pms2 (Ref Lab),3108834105,CDM,310,RC,88341,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Msh6 (Ref Lab),3108834106,CDM,310,RC,88341,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunohisto Antibody Slide (Ref Lab),3108834107,CDM,310,RC,88341,HCPCS,,,facility,both,,,,177,132.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ihpca-Imhchem/Imcytchm Ea Addl Single Antb Stain Px,3108834108,CDM,310,RC,88341,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ihpca-Imhchem/Imcytchm Ea Addl Single Antb Stain Px,3108834108,CDM,310,RC,88341,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ihc Antibody Stain (Ref Lab),3108834201,CDM,310,RC,88342,HCPCS,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histo/Cyto Stain Ip (Ref Lab),3108834202,CDM,310,RC,88342,HCPCS,,,facility,both,,,,306,229.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mlh1 (Ref Lab),3108834203,CDM,310,RC,88342,HCPCS,,,facility,both,,,,262,196.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Immunohistochemist (Ref Lab),3108834204,CDM,310,RC,88342,HCPCS,,,facility,both,,,,204,153,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arup/Incyte - Immunohistochemistry Or Immunocytochemistry, Per Specimen; Initial Single Antibody",3108834206,CDM,310,RC,88342,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arup/Incyte - Immunohistochemistry Or Immunocytochemistry, Per Specimen; Initial Single Antibody",3108834206,CDM,310,RC,88342,HCPCS,,,facility,both,,,,101,75.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Ihpci-Imhchem/Imcytchm 1St Single Antb Stain Procedure,3108834207,CDM,310,RC,88342,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ihpci-Imhchem/Imcytchm 1St Single Antb Stain Procedure,3108834207,CDM,310,RC,88342,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Immunocytochem Stain Mplex (Ref Lab),3108834402,CDM,310,RC,88344,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Surg If Initial Tc (Outside Ref Lab),3108834601,CDM,310,RC,88346,HCPCS,,,facility,both,,,,383,287.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ibd Specific Panca Ifa Perinuc (Outside Ref Lab),3108834602,CDM,310,RC,88346,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Cifa-Cutaneous Immunofluorescence Antibodies, Iga",3108834603,CDM,310,RC,88346,HCPCS,,,facility,both,,,,282,211.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Cifa-Cutaneous Immunofluorescence Antibodies, Iga",3108834603,CDM,310,RC,88346,HCPCS,,,facility,both,,,,282,211.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Cifs-Cutaneous Immunofluorescence Antibodies, Igg",3108834604,CDM,310,RC,88346,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Cifs-Cutaneous Immunofluorescence Antibodies, Igg",3108834604,CDM,310,RC,88346,HCPCS,,,facility,both,,,,78,58.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cib-Immunofluorescence Per Spec 1St Single Antb Stn,3108834605,CDM,310,RC,88346,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cib-Immunofluorescence Per Spec 1St Single Antb Stn,3108834605,CDM,310,RC,88346,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Electron Microscopy Diagnostic (Ref Lab),3108834801,CDM,310,RC,88348,HCPCS,,,facility,both,,,,1653,1239.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arkana: Electron Microscopy, Diagnostic",3108834802,CDM,310,RC,88348,HCPCS,,,facility,both,,,,616,462,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arkana: Electron Microscopy Diagnostic- Reduced,3108834803,CDM,310,RC,88348,HCPCS,,,facility,both,,,,504,378,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Cifa-Cutaneous Immunofluorescence Antibodies, Iga",3108835001,CDM,310,RC,88350,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Cifa-Cutaneous Immunofluorescence Antibodies, Iga",3108835001,CDM,310,RC,88350,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Cifs-Cutaneous Immunofluorescence Antibodies, Igg",3108835002,CDM,310,RC,88350,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Cifs-Cutaneous Immunofluorescence Antibodies, Igg",3108835002,CDM,310,RC,88350,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cib-Immunofluorescence Pr Spec Ea Add Singl Antb Stn,3108835003,CDM,310,RC,88350,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cib-Immunofluorescence Pr Spec Ea Add Singl Antb Stn,3108835003,CDM,310,RC,88350,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Histo/Cyto Morph An,Tumor Ihc",3108836001,CDM,310,RC,88360,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Histo/Cyto Morph An,Tumor Ihc",3108836001,CDM,310,RC,88360,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Caris; Morphometric Analysis, Tumor Ihc",3108836002,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Caris; Morphometric Analysis, Tumor Ihc",3108836002,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Caris - Trk A/B/C (Ref Lab),3108836003,CDM,310,RC,88360,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Caris - Alk Ihc,Pd-L1 (22C3)-1 (Ref Lab)",3108836004,CDM,310,RC,88360,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Caris - Alk Ihc,Pd-L1 (22C3)-2 (Ref Lab)",3108836005,CDM,310,RC,88360,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Caris - Alk Ihc,Pd-L1 (22C3)-3 (Ref Lab)",3108836006,CDM,310,RC,88360,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Caris - Er (Ref Lab),3108836007,CDM,310,RC,88360,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Caris - Erbb2 (Ref Lab),3108836008,CDM,310,RC,88360,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Caris - Pr (Ref Lab),3108836009,CDM,310,RC,88360,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Caris - Braf V600E (Ref Lab),3108836010,CDM,310,RC,88360,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neo Genomics - Fda Pd-L1 (Ref Lab),3108836011,CDM,310,RC,88360,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Foundation- Tumor Immunohisto (Ref Lab),3108836012,CDM,310,RC,88360,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Caris: Folr1,3108836013,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Caris: Folr1,3108836013,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Non-Mayo-Caris: Egfr Ex19 Del,3108836014,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Non-Mayo-Caris: Egfr Ex19 Del,3108836014,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Caris: Alk Ihc,3108836015,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Caris: Alk Ihc,3108836015,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Caris: Ros1,3108836016,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Caris: Ros1,3108836016,CDM,310,RC,88360,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Dll3-M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual,3108836017,CDM,310,RC,88360,HCPCS,,,facility,both,,,,501,375.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Dll3-M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual,3108836017,CDM,310,RC,88360,HCPCS,,,facility,both,,,,501,375.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Neogenomics: M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual,3108836018,CDM,310,RC,88360,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neogenomics: M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual,3108836018,CDM,310,RC,88360,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Insitu Hybridiaztion (Fish),3108836401,CDM,310,RC,88364,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insitu Hybridiaztion (Fish),3108836401,CDM,310,RC,88364,HCPCS,,,facility,both,,,,291,218.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Univ Of Wa-In Situ Hybridization Ea Addl Probe Stain,3108836402,CDM,310,RC,88364,HCPCS,,,facility,both,,,26,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
Hc Univ Of Wa-In Situ Hybridization Ea Addl Probe Stain,3108836402,CDM,310,RC,88364,HCPCS,,,facility,both,,,26,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
Hc Mayo Ispca-In Situ Hybridization Ea Addl Probe Stain,3108836403,CDM,310,RC,88364,HCPCS,,,facility,both,,,,573,429.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ispca-In Situ Hybridization Ea Addl Probe Stain,3108836403,CDM,310,RC,88364,HCPCS,,,facility,both,,,,573,429.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Available For Use,3108836501,CDM,310,RC,88365,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Histo/Cyto In Situ Hybrid/Ish (Ref Lab),3108836502,CDM,310,RC,88365,HCPCS,,,facility,both,,,,317,237.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histo/Cyto In Situ Hybrid/Ish (Ref Lab),3108836502,CDM,310,RC,88365,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Univ Of Wa-In Situ Hybridization 1St Probe Stain,3108836503,CDM,310,RC,88365,HCPCS,,,facility,both,,,26,84,63,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
Hc Univ Of Wa-In Situ Hybridization 1St Probe Stain,3108836503,CDM,310,RC,88365,HCPCS,,,facility,both,,,26,84,63,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
Hc Mayo Ispci-In Situ Hybridization 1St Probe Stain,3108836504,CDM,310,RC,88365,HCPCS,,,facility,both,,,,573,429.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Ispci-In Situ Hybridization 1St Probe Stain,3108836504,CDM,310,RC,88365,HCPCS,,,facility,both,,,,573,429.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Neogenomics: In Situ Hybridization, Initial Single Probe",3108836505,CDM,310,RC,88365,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Neogenomics: In Situ Hybridization, Initial Single Probe",3108836505,CDM,310,RC,88365,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Fish Auto Multiplex, Ea (Ref Lab)",3108837401,CDM,310,RC,88374,HCPCS,,,facility,both,,,,478,358.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc M/Phmtrc Alys Ish Quant/Semiq Cptr Each Multiprb (Ref Lab),3108837402,CDM,310,RC,88374,HCPCS,,,facility,both,,,,575,431.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Igh(14Q32) (Ref Lab),3108837403,CDM,310,RC,88374,HCPCS,,,facility,both,,,,478,358.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lung Fish Multiplex, Ea (Ref Lab)",3108837701,CDM,310,RC,88377,HCPCS,,,facility,both,,,,658,493.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb (Ref Lab),3108837702,CDM,310,RC,88377,HCPCS,,,facility,both,,,,527,395.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb (Ref Lab),3108837702,CDM,310,RC,88377,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Caris - Erbb2 (Her2/Neu) Cish (Ref Lab),3108837703,CDM,310,RC,88377,HCPCS,,,facility,both,,,,529,396.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Neogenomics-Fish Manual- Pc (Multiplex Probe), Each",3108837705,CDM,310,RC,88377,HCPCS,,,facility,both,,,,472,354,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Neogenomics-Fish Manual- Pc (Multiplex Probe), Each",3108837705,CDM,310,RC,88377,HCPCS,,,facility,both,,,,472,354,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh  Non Mayo-Neogenomics: Fish Manual-Pc (Multiplex Probe), Each",3108837706,CDM,310,RC,88377,HCPCS,,,facility,both,,,,785,588.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh  Non Mayo-Neogenomics: Fish Manual-Pc (Multiplex Probe), Each",3108837706,CDM,310,RC,88377,HCPCS,,,facility,both,,,,262,196.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo _Praa-M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb,3108837707,CDM,310,RC,88377,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo _Praa-M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb,3108837707,CDM,310,RC,88377,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Blym-M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb,3108837708,CDM,310,RC,88377,HCPCS,,,facility,both,,,,1112,834,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Blym-M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb,3108837708,CDM,310,RC,88377,HCPCS,,,facility,both,,,,1112,834,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Tlym-M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb,3108837709,CDM,310,RC,88377,HCPCS,,,facility,both,,,,1160,870,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Tlym-M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb,3108837709,CDM,310,RC,88377,HCPCS,,,facility,both,,,,1160,870,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Mlcpc-Microdissection (Ie, Sample Preparation Of Microscopically Identified Target); Laser C",3108838001,CDM,310,RC,88380,HCPCS,,,facility,both,,,,1328,996,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Microdissection Manual (Ref Lab),3108838101,CDM,310,RC,88381,HCPCS,,,facility,both,,,,286,214.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
CIPROFLOXACIN 250 MG TABS,31095,CDM,250,RC,58657067501,NDC,,,facility,both,2,UN,,3.95,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG TABS,31095,CDM,250,RC,58657067501,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG TABS,31095,CDM,250,RC,58657067501,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,68084007001,NDC,,,facility,both,1.5,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,65862007701,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,65862007701,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,904724361,NDC,,,facility,both,1.5,UN,,4.29,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,65862007701,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,68084007001,NDC,,,facility,both,1,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,904724361,NDC,,,facility,both,1,UN,,7.78,5.83,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,904724361,NDC,,,facility,both,0.5,UN,,6.26,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,68084007001,NDC,,,facility,both,0.5,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG TABS,31096,CDM,250,RC,62135030901,NDC,,,facility,both,1,UN,,14.8,11.1,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 7.5 MG CAPS,31109,CDM,250,RC,63739000333,NDC,,,facility,both,2,UN,,8.18,6.13,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 7.5 MG CAPS,31109,CDM,250,RC,904643604,NDC,,,facility,both,1,UN,,12.3,9.22,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 7.5 MG CAPS,31109,CDM,250,RC,904643604,NDC,,,facility,both,4,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 7.5 MG CAPS,31109,CDM,250,RC,63739000333,NDC,,,facility,both,1,UN,,10.8,8.1,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 7.5 MG CAPS,31109,CDM,250,RC,63739000333,NDC,,,facility,both,4,UN,,6.89,5.17,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SOLN,31118,CDM,636,RC,J3105,HCPCS,143974610,NDC,facility,both,1,ME,,27.25,20.44,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SOLN,31118,CDM,636,RC,J3105,HCPCS,63323066501,NDC,facility,both,1,ME,,28.35,21.26,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTHERIA TOXOID TD >/= 7 YEARS 5-2 LFU INJ,31151,CDM,636,RC,90714,HCPCS,49281021515,NDC,facility,both,0.5,ML,,103.47,77.6,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ,31151,CDM,49281021515,NDC,,,,,facility,both,0.5,ML,,76.95,57.71,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Cyto Smears With Interp (Ref Lab),3118810401,CDM,311,RC,88104,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cyto Sm Conc In, Scni (Ref Lab)",3118810801,CDM,311,RC,88108,HCPCS,,,facility,both,,,,259,194.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Histo/Cyto Cell Enhance,Interp (Ref Lab)",3118811202,CDM,311,RC,88112,HCPCS,,,facility,both,,,,247,185.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cytopath C/V Thin Layer,3118814201,CDM,311,RC,88142,HCPCS,,,facility,both,,,,48,36,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Cytopath Smear Other Source,3118816001,CDM,311,RC,88160,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cytopath Smear Other Source,3118816001,CDM,311,RC,88160,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Histo Fine Needle Eval (Ref Lab),3118817201,CDM,311,RC,88172,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incyte: Cytp Dx Eval Fna 1St Ea Site,3118817202,CDM,311,RC,88172,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Incyte: Cytp Dx Eval Fna 1St Ea Site,3118817202,CDM,311,RC,88172,HCPCS,,,facility,both,,,,22,16.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Histo Fine Needle Int,Rep (Ref Lab)",3118817301,CDM,311,RC,88173,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Histo Fine Needle Int,Rep (Ref Lab)",3118817301,CDM,311,RC,88173,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Cytopath C/V Auto Fl Redo Tc,3118817501,CDM,311,RC,88175,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cytopath C/V Auto Fl Redo Tc,3118817501,CDM,311,RC,88175,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Histo Fine Needle Eval,Ea Addl (Ref Lab)",3118817701,CDM,311,RC,88177,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incyte: Cytp Fna Eval Ea Addl,3118817702,CDM,311,RC,88177,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incyte: Cytp Fna Eval Ea Addl,3118817702,CDM,311,RC,88177,HCPCS,,,facility,both,,,,3.45,2.59,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Flow Cytometry,1St Marker",3118818401,CDM,311,RC,88184,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cyto, First, Hematologics (Ref Lab)",3118818402,CDM,311,RC,88184,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flowcytometry, 1St Marker (Ref Lab)",3118818403,CDM,311,RC,88184,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Flowcytometric/ Tc 1 Marker (Ref Lab),3118818404,CDM,311,RC,88184,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, Rbc (Ref Lab)",3118818405,CDM,311,RC,88184,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, Wbc (Ref Lab)",3118818406,CDM,311,RC,88184,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, 1St Marker (Ref Lab)",3118818407,CDM,311,RC,88184,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Band 3 Fluorescence Stain, Rbc (Ref Lab)",3118818408,CDM,311,RC,88184,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Band 3 Fluorescence Stain, Rbc (Ref Lab)",3118818408,CDM,311,RC,88184,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Fetomaternal Bleed, Flow Cytometry, Blood (Ref Lab)",3118818409,CDM,311,RC,88184,HCPCS,,,facility,both,,,,582,436.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fetomaternal Bleed, Flow Cytometry, Blood (Ref Lab)",3118818409,CDM,311,RC,88184,HCPCS,,,facility,both,,,,582,436.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Ige Receptor Antibody (Ref Lab),3118818410,CDM,311,RC,88184,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/ Tc 1 Marker,3118818411,CDM,311,RC,88184,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/ Tc 1 Marker,3118818411,CDM,311,RC,88184,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/ Tc 1 Marker,3118818412,CDM,311,RC,88184,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/ Tc 1 Marker,3118818412,CDM,311,RC,88184,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Neogenomics: Flow Cytometry Technique For Dna Or Cell Analysis, First Marker",3118818413,CDM,311,RC,88184,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Neogenomics: Flow Cytometry Technique For Dna Or Cell Analysis, First Marker",3118818413,CDM,311,RC,88184,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Szdia First-Flow Cytometry Technique For Dna Or Cell Analysis, First Marker",3118818414,CDM,311,RC,88184,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Szdia First-Flow Cytometry Technique For Dna Or Cell Analysis, First Marker",3118818414,CDM,311,RC,88184,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Flow Cytometry Cell Surf Marker Techl Only 1St,3118818415,CDM,311,RC,88184,HCPCS,,,facility,both,,,,799,599.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Haev1-Flow Cytometry Cell Surf Marker Techl Only 1St,3118818415,CDM,311,RC,88184,HCPCS,,,facility,both,,,,799,599.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cllmd-Flow Cytometry Cell Surf Marker Techl Only 1St,3118818416,CDM,311,RC,88184,HCPCS,,,facility,both,,,,269,201.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry,Add Markers",3118818501,CDM,311,RC,88185,HCPCS,,,facility,both,,,,133,99.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cyto, Add-On,Hematologics (Ref Lab)",3118818502,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flowcytometry, Add Marker 1 (Ref Lab)",3118818503,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flowcytometry, Add Marker 2 (Ref Lab)",3118818504,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flowcytometry, Add Marker 3 (Ref Lab)",3118818505,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flowcytometry, Add Marker 4 (Ref Lab)",3118818506,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flowcytometry, Add Marker 5 (Ref Lab)",3118818507,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, Add Marker 1 (Ref Lab)",3118818508,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, Add Marker 2 (Ref Lab)",3118818509,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, Add Marker 3 (Ref Lab)",3118818510,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, Add Marker 4 (Ref Lab)",3118818511,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, Add Marker 5 (Ref Lab)",3118818512,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, Add Marker 6 (Ref Lab)",3118818513,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Flow Cytometry, Add Marker 7 (Ref Lab)",3118818514,CDM,311,RC,88185,HCPCS,,,facility,both,,,,108,81,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818515,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818515,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818516,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818516,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818517,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818517,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818518,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818518,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818519,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818519,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818520,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818520,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818521,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Plink Flowcytometry/Tc Add-On,3118818521,CDM,311,RC,88185,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Neogenomics: Flow Cytometry Technique For Dna Or Cell Analysis, Each Additional Marker",3118818522,CDM,311,RC,88185,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Neogenomics: Flow Cytometry Technique For Dna Or Cell Analysis, Each Additional Marker",3118818522,CDM,311,RC,88185,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Szdia Add1-Flow Cytometry Technique For Dna Or Cell Analysis, Each Additional Marker",3118818523,CDM,311,RC,88185,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Szdia Add1-Flow Cytometry Technique For Dna Or Cell Analysis, Each Additional Marker",3118818523,CDM,311,RC,88185,HCPCS,,,facility,both,,,,20,15,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cllmd-Flow Cytometry Cell Surf Marker Techl Only Ea,3118818524,CDM,311,RC,88185,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Flowcytometry Read 2-8 (Ref Lab),3118818701,CDM,311,RC,88187,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Neogenomics: Flow Cytometry Technique For Dna Or Cell Analysis, 2 To 8 Markers",3118818702,CDM,311,RC,88187,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Neogenomics: Flow Cytometry Technique For Dna Or Cell Analysis, 2 To 8 Markers",3118818702,CDM,311,RC,88187,HCPCS,,,facility,both,,,,95,71.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Chrcb-Chromo Analys,Culture 01 (Ref Lab)",3118823001,CDM,311,RC,88230,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fibroblast Culture For Genetic Test (Ref Lab),3118823301,CDM,311,RC,88233,HCPCS,,,facility,both,,,,330,247.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Culfb Tissue Culture Skin/Biopsy,3118823302,CDM,311,RC,88233,HCPCS,,,facility,both,,,,208,156,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Culfb Tissue Culture Skin/Biopsy,3118823302,CDM,311,RC,88233,HCPCS,,,facility,both,,,,208,156,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Fibr-Fibroblast Culture,3118823303,CDM,311,RC,88233,HCPCS,,,facility,both,,,,382,286.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Fibr-Fibroblast Culture,3118823303,CDM,311,RC,88233,HCPCS,,,facility,both,,,,382,286.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Culture For Genetic Testing, Amniotic Fluid (Ref Lab)",3118823501,CDM,311,RC,88235,HCPCS,,,facility,both,,,,428,321,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Culaf Tissue Culture Placenta,3118823502,CDM,311,RC,88235,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Culaf Tissue Culture Placenta,3118823502,CDM,311,RC,88235,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Tissue Culture For Neoplastic Disorders; Solid Tumor,3118823901,CDM,311,RC,88239,HCPCS,,,facility,both,,,,131,98.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tissue Culture For Neoplastic Disorders; Solid Tumor,3118823901,CDM,311,RC,88239,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cryoprsrv Frzing&Storage Cells Ea Cell Line (Ref Lab),3118824001,CDM,311,RC,88240,HCPCS,,,facility,both,,,,298,223.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Culfb Cell Cryopreserve/Storage,3118824002,CDM,311,RC,88240,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Culfb Cell Cryopreserve/Storage,3118824002,CDM,311,RC,88240,HCPCS,,,facility,both,,,,208,156,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Culaf Cell Cryopreserve/Storage,3118824003,CDM,311,RC,88240,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Culaf Cell Cryopreserve/Storage,3118824003,CDM,311,RC,88240,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo  Cryob-Cryo For Biochem Studies,3118824004,CDM,311,RC,88240,HCPCS,,,facility,both,,,,2668,2001,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo  Cryob-Cryo For Biochem Studies,3118824004,CDM,311,RC,88240,HCPCS,,,facility,both,,,,298,223.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Cytogenetics Dna Probe 1 (Ref Lab),3118827101,CDM,311,RC,88271,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cytogenetics Dna Probe 2 (Ref Lab),3118827102,CDM,311,RC,88271,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Dd22F- Molecular Cytogenetics; Dna Probe, Each (Eg, Fish)",3118827103,CDM,311,RC,88271,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Chrnic Lymph Leukemia Cll,Fish (Ref Lab)",3118827104,CDM,311,RC,88271,HCPCS,,,facility,both,,,,340,255,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Molecular Cytogenetc (Ie Fish) (Ref Lab),3118827105,CDM,311,RC,88271,HCPCS,,,facility,both,,,,844,633,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cytogenetics Dna Probe (Ref Lab),3118827106,CDM,311,RC,88271,HCPCS,,,facility,both,,,,206,154.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Chic2 (4Q12) Deletion, Fish (Ref Lab)",3118827107,CDM,311,RC,88271,HCPCS,,,facility,both,,,,330,247.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nadf Cytogenetics Dna Probe,3118827108,CDM,311,RC,88271,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nadf Cytogenetics Dna Probe,3118827108,CDM,311,RC,88271,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh  Mayo Nadf Cytogenetics Dna Probe,3118827109,CDM,311,RC,88271,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh  Mayo Nadf Cytogenetics Dna Probe,3118827109,CDM,311,RC,88271,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Clldf-Chronic Lymphocytic Leukemia, Diagnostic Fish, Varies",3118827110,CDM,311,RC,88271,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Clldf-Chronic Lymphocytic Leukemia, Diagnostic Fish, Varies",3118827110,CDM,311,RC,88271,HCPCS,,,facility,both,,,,86,64.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Eosdf-Chronic Eosinophilia, Diagnostic Fish",3118827111,CDM,311,RC,88271,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Eosdf-Chronic Eosinophilia, Diagnostic Fish",3118827111,CDM,311,RC,88271,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo Xymf-Known 45, X Mosaicism Reflex, Fish",3118827112,CDM,311,RC,88271,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Xymf-Known 45, X Mosaicism Reflex, Fish",3118827112,CDM,311,RC,88271,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Cllmf-Dna Testing For Genetic Defects,3118827113,CDM,311,RC,88271,HCPCS,,,facility,both,,,,153,114.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Cllmf-Dna Testing For Genetic Defects,3118827113,CDM,311,RC,88271,HCPCS,,,facility,both,,,,1531,1148.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Kh Mayo Mamlf-Molecular Cytogenetics Dna Probe Each,3118827114,CDM,311,RC,88271,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Kh Mayo Mamlf-Molecular Cytogenetics Dna Probe Each,3118827114,CDM,311,RC,88271,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo _Pbct-Probe Set, Count",3118827115,CDM,311,RC,88271,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo _Pbct-Probe Set, Count",3118827115,CDM,311,RC,88271,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Mdm2F-Molecular Cytogenetics Dna Probe Each,3118827116,CDM,311,RC,88271,HCPCS,,,facility,both,,,,254,190.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Mdm2F-Molecular Cytogenetics Dna Probe Each,3118827116,CDM,311,RC,88271,HCPCS,,,facility,both,,,,254,190.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo _Padd-Molecular Cytogenetics Dna Probe Each,3118827117,CDM,311,RC,88271,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo _Padd-Molecular Cytogenetics Dna Probe Each,3118827117,CDM,311,RC,88271,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Mayo Tlblf-Molecular Cytogenetics; Dna Probe, Each (Eg, Fish)",3118827118,CDM,311,RC,88271,HCPCS,,,facility,both,,,,328,246,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mayo Tlblf-Molecular Cytogenetics; Dna Probe, Each (Eg, Fish)",3118827118,CDM,311,RC,88271,HCPCS,,,facility,both,,,,328,246,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hemmf-Molecular Cytogenetics Dna Probe Each,3118827119,CDM,311,RC,88271,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Hemmf-Molecular Cytogenetics Dna Probe Each,3118827119,CDM,311,RC,88271,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Interphases 100-300 (Ref Lab),3118827501,CDM,311,RC,88275,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Interphases 100-300 (Ref Lab),3118827501,CDM,311,RC,88275,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Situ Hybridization Anlyze  (Ref Lab),3118827502,CDM,311,RC,88275,HCPCS,,,facility,both,,,,110,82.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cytogenetics 100-300 (Ref Lab),3118827503,CDM,311,RC,88275,HCPCS,,,facility,both,,,,516,387,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Clldf-Chronic Lymphocytic Leukemia, Diagnostic Fish, Varies",3118827504,CDM,311,RC,88275,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo  Clldf-Chronic Lymphocytic Leukemia, Diagnostic Fish, Varies",3118827504,CDM,311,RC,88275,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Eosdf-Chronic Eosinophilia, Diagnostic Fish",3118827505,CDM,311,RC,88275,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
"Hc Kh Mayo  Eosdf-Chronic Eosinophilia, Diagnostic Fish",3118827505,CDM,311,RC,88275,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cllmf-Chromosome Analysis For Genetic Defects, Analyze 100-300 Cells",3118827506,CDM,311,RC,88275,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Cllmf-Chromosome Analysis For Genetic Defects, Analyze 100-300 Cells",3118827506,CDM,311,RC,88275,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Hemmf-Molec Cytg Interphase Ish Analyze 100-300 Cll,3118827507,CDM,311,RC,88275,HCPCS,,,facility,both,,,,450,337.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Hemmf-Molec Cytg Interphase Ish Analyze 100-300 Cll,3118827507,CDM,311,RC,88275,HCPCS,,,facility,both,,,,450,337.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Hematologics -Add'l Karyotypes (Ref Lab),3118828001,CDM,311,RC,88280,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Enzyme Constituent (Ref Lab),3118831901,CDM,311,RC,88319,HCPCS,,,facility,both,,,,746,559.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Histo/Cyto Ifa Study, Direct",3118834601,CDM,311,RC,88346,HCPCS,,,facility,both,,,,528,396,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Providence - Tc Ida (Ref Lab),3118834602,CDM,311,RC,88346,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
THIAMINE 100 MG TABS,31269,CDM,250,RC,50268085115,NDC,,,facility,both,4,UN,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TABS,31269,CDM,250,RC,50268085115,NDC,,,facility,both,2,UN,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TABS,31269,CDM,250,RC,77333093410,NDC,,,facility,both,2.5,UN,,2.83,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TABS,31269,CDM,250,RC,77333093410,NDC,,,facility,both,1,UN,,7.04,5.28,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TABS,31269,CDM,250,RC,50268085115,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TABS,31269,CDM,250,RC,50268085115,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TABS,31269,CDM,250,RC,50268085115,NDC,,,facility,both,5,UN,,1.95,1.46,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TABS,31269,CDM,250,RC,77333093410,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TABS,31269,CDM,250,RC,77333093410,NDC,,,facility,both,5,UN,,1.89,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Histo Surg Path Gross Only (Ref Lab),3128830001,CDM,312,RC,88300,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histo Surg Path Limited (Ref Lab),3128830201,CDM,312,RC,88302,HCPCS,,,facility,both,,,,288,216,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histo Surg Path 1 L-Iii (Ref Lab),3128830401,CDM,312,RC,88304,HCPCS,,,facility,both,,,,245,183.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histo Surg Path 1 L-Iii (Ref Lab),3128830401,CDM,312,RC,88304,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Histo Surg Path 2 L-Iv 9 (Ref Lab),3128830501,CDM,312,RC,88305,HCPCS,,,facility,both,,,,295.55,221.66,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Cyto Cell Block, Ccb (Ref Lab)",3128830502,CDM,312,RC,88305,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Providence - T2 (Ref Lab),3128830503,CDM,312,RC,88305,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Oregon Hlth- Surgical Patholgy (Ref Lab),3128830504,CDM,312,RC,88305,HCPCS,,,facility,both,,,,282,211.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histo Surg Path 3 L-V (Ref Lab),3128830701,CDM,312,RC,88307,HCPCS,,,facility,both,,,,555,416.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Histo Surg Path 3 L-V (Ref Lab),3128830701,CDM,312,RC,88307,HCPCS,,,facility,both,,,,528,396,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Level V Surg Pathology Gross&Microscopic Exam,3128830702,CDM,312,RC,88307,HCPCS,,,facility,both,,,,528,396,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Histo Surg Path 4 L-Vi (Ref Lab),3128830901,CDM,312,RC,88309,HCPCS,,,facility,both,,,,775,581.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Csppc-Consult, W/Slide Prep",3128832301,CDM,312,RC,88323,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Kh Mayo Csppc-Consult, W/Slide Prep",3128832301,CDM,312,RC,88323,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Mayo Cuppc - Consultation And Report On Referred Material Requiring Preparation Of Slides,3128832302,CDM,312,RC,88323,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mayo Cuppc - Consultation And Report On Referred Material Requiring Preparation Of Slides,3128832302,CDM,312,RC,88323,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Univ Of Wa-Consultation And Report On Referred Material Requiring Preparation Of Slides,3128832303,CDM,312,RC,88323,HCPCS,,,facility,both,,,TC,155,116.25,,,,,,,,,,"Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge | The modified price is presented in the standard charge value. | Modifier TC: Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha"
Hc Univ Of Wa-Consultation And Report On Referred Material Requiring Preparation Of Slides,3128832303,CDM,312,RC,88323,HCPCS,,,facility,both,,,TC,155,116.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier TC: Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha"
"Hc Histo/Cyto Morph Anlys,Ish,Qnt (Ref Lab)",3128836801,CDM,312,RC,88368,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mphmtric Ish Manual Per Spec (Ref Lab),3128836802,CDM,312,RC,88368,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
THROMBIN 5000 UNITS SOLR,31302,CDM,250,RC,MHS5000UNITS,HCPCS,60793021505,NDC,facility,both,5000,UN,,89.05,66.79,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL 0.25 % SOLN 5 ML BOTTLE,31338,CDM,250,RC,61314022605,NDC,,,facility,both,5,ML,,34.2,25.65,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL 0.25 % SOLN 5 ML BOTTLE,31338,CDM,250,RC,60758080205,NDC,,,facility,both,5,ML,,30.15,22.61,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL 0.25 % SOLN 5 ML BOTTLE,31338,CDM,250,RC,64980051305,NDC,,,facility,both,5,ML,,32.25,24.19,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL 0.5 % SOLN,31339,CDM,250,RC,MHS1ML,HCPCS,60758080105,NDC,facility,both,1,ML,,6.94,5.2,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL 0.5 % SOLN 5 ML BOTTLE,31339,CDM,250,RC,MHS1ML,HCPCS,61314022705,NDC,facility,both,1,ML,,8.36,6.27,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL 0.5 % SOLN 5 ML BOTTLE,31339,CDM,250,RC,MHS1ML,HCPCS,64980051405,NDC,facility,both,1,ML,,7.03,5.27,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SOLR,31352,CDM,636,RC,J3260,HCPCS,39822041201,NDC,facility,both,80,ME,,13.05,9.79,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OINT 3.5 G TUBE,31359,CDM,250,RC,MHS3.5GM,HCPCS,65064835,NDC,facility,both,3.5,GM,,354.5,265.88,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % SUSP 5 ML BOTTLE,31360,CDM,250,RC,MHS0.5ML,HCPCS,61314064705,NDC,facility,both,0.5,ML,,14.39,10.79,,,,,,,,,,Gross Charge Type: Pharmacy
TRETINOIN 0.05 % CREA 20 G TUBE,31389,CDM,250,RC,51672139400,NDC,,,facility,both,20,GR,,173.55,130.16,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG TABS,314,CDM,250,RC,904666361,NDC,,,facility,both,4,UN,,6.79,5.09,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG TABS,314,CDM,250,RC,904666361,NDC,,,facility,both,1,UN,,13.63,10.22,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG TABS,314,CDM,250,RC,904666361,NDC,,,facility,both,1.5,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG TABS,314,CDM,250,RC,904666361,NDC,,,facility,both,3,UN,,7.57,5.67,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG TABS,314,CDM,250,RC,60687061911,NDC,,,facility,both,0.5,UN,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG TABS,314,CDM,250,RC,904666361,NDC,,,facility,both,0.5,UN,,10.63,7.97,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG TABS,314,CDM,250,RC,60687061911,NDC,,,facility,both,2,UN,,9.28,6.96,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG TABS,314,CDM,250,RC,904666361,NDC,,,facility,both,2,UN,,10.05,7.54,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG TABS,314,CDM,250,RC,60687061911,NDC,,,facility,both,1,UN,,13.35,10.01,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE 10 MG/ML SUSP,31413,CDM,636,RC,J3301,HCPCS,3049420,NDC,facility,both,10,ME,,15.45,11.59,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,31413,CDM,3049420,NDC,,,,,facility,both,10,ML,,16.72,12.54,,,,,,,,,,Gross Charge Type: Pharmacy
TRIFLURIDINE 1 % SOLN 7.5 ML BOTTLE,31447,CDM,250,RC,61314004475,NDC,,,facility,both,7.5,ML,,285.6,214.2,,,,,,,,,,Gross Charge Type: Pharmacy
POLYMYXIN B-TRIMETHOPRIM 10000 UNIT/ML - 1 MG/ML SOLN 10 ML BOTTLE,31466,CDM,250,RC,MHS1ML,HCPCS,61314062810,NDC,facility,both,1,ML,,3.76,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,31474,CDM,250,RC,57237023301,NDC,,,facility,both,1.5,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,31474,CDM,250,RC,57237023301,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,31474,CDM,250,RC,57237023301,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,31474,CDM,250,RC,904272561,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,31474,CDM,250,RC,904272561,NDC,,,facility,both,3,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,31474,CDM,250,RC,904272561,NDC,,,facility,both,2,UN,,3.98,2.98,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,31474,CDM,250,RC,904272561,NDC,,,facility,both,1.5,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,31474,CDM,250,RC,904272561,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG TABS,31477,CDM,250,RC,68084027001,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG TABS,31477,CDM,250,RC,68084027001,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG TABS,31477,CDM,250,RC,68084027001,NDC,,,facility,both,4,UN,,2.41,1.81,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG TABS,31477,CDM,250,RC,68084027001,NDC,,,facility,both,3,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG TABS,31477,CDM,250,RC,43547033906,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG TABS,31478,CDM,250,RC,50458030201,NDC,,,facility,both,2,UN,,12.4,9.3,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG TABS,31478,CDM,250,RC,50458030201,NDC,,,facility,both,4,UN,,9.9,7.42,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG TABS,31478,CDM,250,RC,904736161,NDC,,,facility,both,2,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG TABS,31478,CDM,250,RC,50458030201,NDC,,,facility,both,1,UN,,16.9,12.68,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG TABS,31478,CDM,250,RC,904736161,NDC,,,facility,both,4,UN,,2.25,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG TABS,31478,CDM,250,RC,904736161,NDC,,,facility,both,3,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG TABS,31478,CDM,250,RC,904736161,NDC,,,facility,both,1,UN,,6.96,5.22,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG TABS,31478,CDM,250,RC,50458030201,NDC,,,facility,both,0.5,UN,,12.55,9.41,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG TABS,31484,CDM,250,RC,93727156,NDC,,,facility,both,1,UN,,5.95,4.47,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG TABS,31484,CDM,250,RC,93727156,NDC,,,facility,both,3,UN,,3.17,2.37,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG TABS,31484,CDM,250,RC,93727156,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG TABS,31484,CDM,250,RC,33342005407,NDC,,,facility,both,1,UN,,5.61,4.21,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG TABS,31484,CDM,250,RC,33342005407,NDC,,,facility,both,3,UN,,2.83,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 30 MG TABS,31485,CDM,250,RC,93727256,NDC,,,facility,both,1,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 30 MG TABS,31485,CDM,250,RC,93727256,NDC,,,facility,both,0.5,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 30 MG TABS,31485,CDM,250,RC,33342005507,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 100 MG/ML SOLR,315,CDM,636,RC,J1120,HCPCS,23155031331,NDC,facility,both,500,ME,,105.35,79.02,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 100 MG/ML SOLR,315,CDM,636,RC,J1120,HCPCS,143950301,NDC,facility,both,500,ME,,100.57,75.43,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 100 MG/ML SOLR,315,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,both,500,ME,,107.87,80.91,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 100 MG/ML SOLR,315,CDM,636,RC,J1120,HCPCS,39822019007,NDC,facility,both,500,ME,,130.05,97.54,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 100 MG/ML SOLR,315,CDM,636,RC,J1120,HCPCS,67457085350,NDC,facility,both,500,ME,,113.48,85.11,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG CAPS,31576,CDM,250,RC,904716861,NDC,,,facility,both,1,UN,,14.3,10.72,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG CAPS,31576,CDM,250,RC,60687010001,NDC,,,facility,both,1,UN,,19.25,14.44,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG CAPS,31576,CDM,250,RC,904716861,NDC,,,facility,both,4,UN,,7.66,5.75,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG CAPS,31576,CDM,250,RC,904716861,NDC,,,facility,both,2,UN,,10,7.5,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG CAPS,31576,CDM,250,RC,904716861,NDC,,,facility,both,3,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN-PYRIDOXINE 3-10 MG TBCR,31581,CDM,250,RC,47469000458,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN-PYRIDOXINE 3-10 MG TBCR,31581,CDM,250,RC,47469000458,NDC,,,facility,both,3,UN,,2.33,1.75,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN-PYRIDOXINE 3-10 MG TBCR,31581,CDM,250,RC,47469000458,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG CAPS,31589,CDM,250,RC,62559039050,NDC,,,facility,both,2,UN,,2.38,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG CAPS,31589,CDM,250,RC,68180016611,NDC,,,facility,both,2,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG CAPS,31589,CDM,250,RC,62559039050,NDC,,,facility,both,1,UN,,10.2,7.65,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG CAPS,31589,CDM,250,RC,68180016611,NDC,,,facility,both,1,UN,,11.9,8.92,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG CAPS,31589,CDM,250,RC,62559039050,NDC,,,facility,both,3,UN,,4.95,3.71,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG CAPS,31589,CDM,250,RC,62559039050,NDC,,,facility,both,4,UN,,4.24,3.18,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 50 MG/ML 50 MG/ML SOLR,31591,CDM,250,RC,MHS1ML,HCPCS,65628020810,NDC,facility,both,1,ML,,2.58,1.93,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 50 MG/ML 50 MG/ML SOLR,31591,CDM,250,RC,65628020810,NDC,,,facility,both,1,ML,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM SOLR,31597,CDM,250,RC,MHS1MG,HCPCS,47335093144,NDC,facility,both,1,ME,,7.09,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG TABS,31692,CDM,250,RC,832121101,NDC,,,facility,both,3.5,UN,,2.18,1.63,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG TABS,31692,CDM,250,RC,832121101,NDC,,,facility,both,6,UN,,1.58,1.19,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG TABS,31692,CDM,250,RC,832121101,NDC,,,facility,both,2.5,UN,,2.73,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG TABS,31692,CDM,250,RC,832121101,NDC,,,facility,both,2,UN,,2.99,2.24,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG TABS,31692,CDM,250,RC,832121101,NDC,,,facility,both,3,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG TABS,31692,CDM,250,RC,832121101,NDC,,,facility,both,1,UN,,6.09,4.56,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG TABS,31692,CDM,250,RC,832121101,NDC,,,facility,both,4,UN,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG TABS,31692,CDM,250,RC,832121101,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Xr Femur 1 View,3207355101,CDM,320,RC,73551,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Xr Lymphangiogram Bilateral,3207580701,CDM,320,RC,75807,HCPCS,,,facility,both,,,,2944,2208,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xray Tube Check,3207649901,CDM,320,RC,76499,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc X-Ray Stress View,3207707101,CDM,320,RC,77071,HCPCS,,,facility,both,,,,247,185.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"CLINIMIX/DEXTROSE (4.25/5) (BASE SOLN CONTAINS: AC 37 MEQ/L; CL 17 MEQ/L) 4.25 % SOLN 2,000 ML FLEX CONT",32261,CDM,250,RC,338108904,NDC,,,facility,both,2000,ML,,145.15,108.86,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX/DEXTROSE (4.25/5) 4.25 % SOLN 1,000 ML PLAS CONT",32261,CDM,250,RC,338113303,NDC,,,facility,both,1000,ML,,101.55,76.16,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX/DEXTROSE (4.25/5) 4.25 % SOLN 2,000 ML FLEX CONT",32261,CDM,250,RC,338108904,NDC,,,facility,both,2000,ML,,145.15,108.86,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX/DEXTROSE (4.25/5) 4.25 % SOLN 2,000 ML FLEX CONT",32261,CDM,250,RC,338108904,NDC,,,facility,both,1000,ML,,97.75,73.31,,,,,,,,,,Gross Charge Type: Pharmacy
"CLINIMIX/DEXTROSE (5/15) 5 % SOLN 2,000 ML FLEX CONT",32271,CDM,250,RC,338109904,NDC,,,facility,both,2000,ML,,163.1,122.32,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARIDE CONJUGATE VACCINE SOLR,32331,CDM,636,RC,90648,HCPCS,49281054503,NDC,facility,both,0.5,ML,,83.7,62.78,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,63739056010,NDC,,,facility,both,3,UN,,3.85,2.89,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,63739056010,NDC,,,facility,both,1.5,UN,,4.8,3.6,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,63739056010,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,71093011104,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,16714033001,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,63739056010,NDC,,,facility,both,2,UN,,5.15,3.86,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,63739056010,NDC,,,facility,both,0.5,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,71093011104,NDC,,,facility,both,2,UN,,3.95,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,16714033001,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 600 MG TABS,32490,CDM,250,RC,71093011104,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 800 MG TABS,32491,CDM,250,RC,16714033201,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 800 MG TABS,32491,CDM,250,RC,60687051801,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 800 MG TABS,32491,CDM,250,RC,16714033201,NDC,,,facility,both,1,UN,,7.16,5.37,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 800 MG TABS,32491,CDM,250,RC,60687051801,NDC,,,facility,both,1.5,UN,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 800 MG TABS,32491,CDM,250,RC,60687051801,NDC,,,facility,both,0.5,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 800 MG TABS,32491,CDM,250,RC,16714033201,NDC,,,facility,both,1.5,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 800 MG TABS,32491,CDM,250,RC,60687051801,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 800 MG TABS,32491,CDM,250,RC,16714033201,NDC,,,facility,both,2,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG TABS,32703,CDM,250,RC,69618002701,NDC,,,facility,both,2,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG TABS,32703,CDM,250,RC,69618002701,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG TABS,32704,CDM,250,RC,904737661,NDC,,,facility,both,0.5,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG TABS,32704,CDM,250,RC,904737661,NDC,,,facility,both,1,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG TABS,32704,CDM,250,RC,904737661,NDC,,,facility,both,2,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG TABS,32704,CDM,250,RC,904737661,NDC,,,facility,both,3,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
CANDIDA ALBICANS SKN TST ANTGN ID SOLN,3279,CDM,59584013801,NDC,,,,,facility,both,1,ML,,111.7,83.78,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 300 MG TB12,32854,CDM,250,RC,62332002531,NDC,,,facility,both,1,UN,,14.75,11.06,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 300 MG TB12,32854,CDM,250,RC,62332002531,NDC,,,facility,both,1.5,UN,,8.92,6.69,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE CR 8 MEQ TBCR,33015,CDM,250,RC,832532211,NDC,,,facility,both,1.25,UN,,3.78,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE CR 8 MEQ TBCR,33015,CDM,250,RC,832532211,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE CR 8 MEQ TBCR,33015,CDM,250,RC,832532211,NDC,,,facility,both,2,UN,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 25 MG TABS,33064,CDM,250,RC,68084089625,NDC,,,facility,both,1.5,UN,,5.12,3.84,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 25 MG TABS,33064,CDM,250,RC,68084089625,NDC,,,facility,both,1,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 25 MG TABS,33064,CDM,250,RC,68084089625,NDC,,,facility,both,2,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 25 MG TABS,33064,CDM,250,RC,68084089625,NDC,,,facility,both,3,UN,,4.23,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 25 MG TABS,33064,CDM,250,RC,68084089625,NDC,,,facility,both,4,UN,,3.56,2.67,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG TABS,33067,CDM,250,RC,68084085601,NDC,,,facility,both,0.5,UN,,8.05,6.04,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG TABS,33067,CDM,250,RC,68084085601,NDC,,,facility,both,3,UN,,3.62,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG TABS,33067,CDM,250,RC,68084085601,NDC,,,facility,both,1,UN,,8.9,6.67,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG TABS,33067,CDM,250,RC,68084085601,NDC,,,facility,both,0.6667,UN,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG TABS,33067,CDM,250,RC,68084085601,NDC,,,facility,both,1.3333,UN,,4.78,3.58,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG TABS,33067,CDM,250,RC,68084085601,NDC,,,facility,both,2,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG TABS,33067,CDM,250,RC,68084085601,NDC,,,facility,both,1.5,UN,,4.9,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 37.5 MG TABS,33068,CDM,250,RC,68084084401,NDC,,,facility,both,2,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 37.5 MG TABS,33068,CDM,250,RC,68084084401,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
DORNASE ALFA 2.5 MG/2.5ML SOLN,33077,CDM,250,RC,J7639,HCPCS,50242010040,NDC,facility,both,1,ME,,69.8,52.35,,,,,,,,,,Gross Charge Type: Pharmacy
DORNASE ALFA 2.5 MG/2.5ML SOLN,33077,CDM,250,RC,50242010040,NDC,,,facility,both,1,ME,,202,151.5,,,,,,,,,,Gross Charge Type: Pharmacy
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,33077,CDM,250,RC,J7639,HCPCS,50242010040,NDC,facility,both,1,ME,,79.4,59.55,,,,,,,,,,Gross Charge Type: Pharmacy
DORNASE ALFA 2.5 MG/2.5ML SOLN 2.5 ML PLAS CONT,33077,CDM,250,RC,50242010040,NDC,,,facility,both,1,ME,,186.76,140.07,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % SOLN,331,CDM,250,RC,MHS1ML,HCPCS,517760425,NDC,facility,both,1,ML,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % SOLN,331,CDM,250,RC,MHS1ML,HCPCS,63323069404,NDC,facility,both,1,ML,,9.88,7.41,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A SOLR,33286,CDM,636,RC,J0585,HCPCS,23114502,NDC,facility,both,1,UN,,14.65,10.99,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A SOLR,33286,CDM,636,RC,J0585,HCPCS,23114501,NDC,facility,both,1,UN,,14.62,10.97,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,33286,CDM,23114501,NDC,,,,,facility,both,1,EA,,15.79,11.84,,,,,,,,,,Gross Charge Type: Pharmacy
MENTHOL-METHYL SALICYCLATE 10-15 % CREA,33722,CDM,250,RC,536134957,NDC,,,facility,both,1,GR,,24.11,18.09,,,,,,,,,,Gross Charge Type: Pharmacy
MENTHOL-METHYL SALICYCLATE 10-15 % CREA,33722,CDM,250,RC,57896011603,NDC,,,facility,both,1,GR,,21.15,15.86,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.5 MG TABS,33742,CDM,250,RC,555089902,NDC,,,facility,both,2,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.5 MG TABS,33742,CDM,250,RC,555089902,NDC,,,facility,both,4,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.5 MG TABS,33742,CDM,250,RC,555089902,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.5 MG TABS,33742,CDM,250,RC,555089902,NDC,,,facility,both,3,UN,,2.58,1.94,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.5 MG TABS,33742,CDM,250,RC,555089902,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
CARTEOLOL 1% SOLN 5 ML BOTTLE,33788,CDM,250,RC,61314023805,NDC,,,facility,both,5,ML,,31.55,23.66,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML SOLN,33900,CDM,636,RC,J1626,HCPCS,63323031801,NDC,facility,both,0.1,ME,,5.43,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML SOLN,33900,CDM,636,RC,J1626,HCPCS,143974410,NDC,facility,both,0.1,ME,,4.36,3.27,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML SOLN 1 ML VIAL,33900,CDM,636,RC,J1626,HCPCS,63323031801,NDC,facility,both,0.1,ME,,7.99,6,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML SOLN 1 ML VIAL,33900,CDM,636,RC,J1626,HCPCS,143974410,NDC,facility,both,0.1,ME,,4.36,3.27,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5ML LIQD,33936,CDM,250,RC,MHS1ML,HCPCS,50580053501,NDC,facility,both,1,ML,,1.03,0.77,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM SVN 0.02 % SOLN,33989,CDM,250,RC,MHS1ML,HCPCS,487980101,NDC,facility,both,1,ML,,4.08,3.06,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM SVN 0.02 % SOLN,33989,CDM,250,RC,MHS1ML,HCPCS,378797055,NDC,facility,both,1,ML,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Thyroid Carcinoma Mets Uptake,3417802001,CDM,341,RC,78020,HCPCS,,,facility,both,,,,894,670.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gastric Emptying Study,3417826501,CDM,341,RC,78265,HCPCS,,,facility,both,,,,1869,1401.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc  Technetium Tc-99M Tilmanocept, Diagnostic, Up To 0.5 Millicuries",343A952001,CDM,343,RC,A9520,HCPCS,,,facility,both,,,,1054,790.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Radiopharmaceuti,343A952001_658570450,CDM,343,RC,A9520,HCPCS,,,facility,both,,,,1054,790.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Radiopharmaceuti,343A952001_658574500,CDM,343,RC,A9520,HCPCS,,,facility,both,,,,1021.69,766.27,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Nm Tc-99M Sulfur Colloid Dx Up To 20 Mci, Filtered - A9541",343A954101,CDM,343,RC,A9541,HCPCS,,,facility,both,,,,491,368.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Radiopharmaceuti,343A954101_455670030,CDM,343,RC,A9541,HCPCS,,,facility,both,,,,476.82,357.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Nm Tc-99M Sulfur Colloid Dx Up To 20 Mci, Unfiltered - A9541",343A954102,CDM,343,RC,A9541,HCPCS,,,facility,both,,,,251,188.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Radiopharmaceuti,343A954102_455670030,CDM,343,RC,A9541,HCPCS,,,facility,both,,,,245.69,184.27,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Radiopharmaceuti,343A954102_658570500,CDM,343,RC,A9541,HCPCS,,,facility,both,,,,251,188.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc A9569 Technet Tc-99M Auto Wbc,343A956901,CDM,343,RC,A9569,HCPCS,,,facility,both,,,,3046,2284.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pet A9580 Pet Na F-18,343A958001,CDM,343,RC,A9580,HCPCS,,,facility,both,,,,716,537,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc F-18 Fluciclovin Per Mci,343A958801,CDM,343,RC,A9588,HCPCS,,,facility,both,,,,1048,786,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Radiopharmaceuti,343A958801_699320001,CDM,343,RC,A9588,HCPCS,,,facility,both,,,,989,741.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Cu-64 Dotatate Per Mci,343A959201,CDM,343,RC,A9592,HCPCS,,,facility,both,,,,1544.55,1158.41,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Radiopharmaceuti,343A959201_400280511,CDM,343,RC,A9592,HCPCS,,,facility,both,,,,1471,1103.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Radiopharmaceuti,343A959201_699450064,CDM,343,RC,A9592,HCPCS,,,facility,both,,,,1429.5,1072.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Piflufolastat F-18 Diagnostic 1 Millicurie,343A959501,CDM,343,RC,A9595,HCPCS,,,facility,both,,,,1219.05,914.29,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Radiopharmaceuti,343A959501_712580022,CDM,343,RC,A9595,HCPCS,,,facility,both,,,,1161,870.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Gallium Ga-68 Gozetotide Diagnositc (Illuccix) 1 Millicurie,343A959601,CDM,343,RC,A9596,HCPCS,,,facility,both,,,,2092.65,1569.49,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Radiopharmaceuti,343A959601_400280511,CDM,343,RC,A9596,HCPCS,,,facility,both,,,,1993,1494.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Radiopharmaceuti,343A959601_747250100,CDM,343,RC,A9596,HCPCS,,,facility,both,,,,1937.74,1453.3,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Flotufolastat F 18, Diagnostic, 1 Millicurie",343A960801,CDM,343,RC,A9608,HCPCS,,,facility,both,,,,1613.85,1210.39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fludeoxyglucose F18 Up To 15 Millicuries,343A960901,CDM,343,RC,A9609,HCPCS,,,facility,both,,,,336,252,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Gallium Ga-68 Gozetotide, Diagnostic, (Locametz), 1 Millicurie",343A980001,CDM,343,RC,A9800,HCPCS,,,facility,both,,,,1887.9,1415.92,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
SENNA 8.6 MG TABS,344,CDM,250,RC,904725261,NDC,,,facility,both,1,UN,,6.24,4.68,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 8.6 MG TABS,344,CDM,250,RC,904725261,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 8.6 MG TABS,344,CDM,250,RC,10135031401,NDC,,,facility,both,2,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 8.6 MG TABS,344,CDM,250,RC,57896045401,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 8.6 MG TABS,344,CDM,250,RC,904725261,NDC,,,facility,both,3,UN,,2.23,1.67,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 8.6 MG TABS,344,CDM,250,RC,10135031401,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
SENNA 8.6 MG TABS,344,CDM,250,RC,904725261,NDC,,,facility,both,4,UN,,1.72,1.29,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 50-200 MG TBCR,34451,CDM,250,RC,16729007901,NDC,,,facility,both,2,UN,,4.95,3.71,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 50-200 MG TBCR,34451,CDM,250,RC,16729007901,NDC,,,facility,both,1.5,UN,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 50-200 MG TBCR,34451,CDM,250,RC,16729007901,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
Hc A9606 Xofigo 1 Microcurie,344A960601,CDM,344,RC,A9606,HCPCS,,,facility,both,,,,0.01,0.01,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Lutetium Lu 177 Vipivotide Tetraxetan, Therapeutic, 1 Millicurie",344A960701,CDM,344,RC,A9607,HCPCS,,,facility,both,,,,478.8,359.1,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Radiopharmaceuti,344A960701_694880010,CDM,344,RC,A9607,HCPCS,,,facility,both,,,,456,342,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
PILOCARPINE 5 MG TABS,34579,CDM,250,RC,68084092825,NDC,,,facility,both,1,UN,,12.5,9.38,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 5 MG TABS,34579,CDM,250,RC,527131301,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
CADEXOMER IODINE 0.9 % GEL 40 G TUBE,34673,CDM,250,RC,40565012249,NDC,,,facility,both,40,GR,,161.33,121,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML SOLN,3471,CDM,255,RC,Q9967,HCPCS,407222316,NDC,facility,both,1,ML,,2,1.5,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML SOLN,3471,CDM,636,RC,Q9967,HCPCS,407222316,NDC,facility,both,1,ML,,1.95,1.46,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML SOLN,3471,CDM,255,RC,Q9967,HCPCS,407222319,NDC,facility,both,1,ML,,1.21,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML SOLN,3471,CDM,636,RC,Q9967,HCPCS,407222317,NDC,facility,both,1,ML,,1.49,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML SOLN,3471,CDM,636,RC,Q9967,HCPCS,407222319,NDC,facility,both,1,ML,,1.24,0.93,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML SOLN,3471,CDM,255,RC,Q9967,HCPCS,407222317,NDC,facility,both,1,ML,,1.49,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG CAPS,34839,CDM,636,RC,J7507,HCPCS,51079081820,NDC,facility,both,1,ME,,6,4.5,,,,,,,,,,Gross Charge Type: Pharmacy
FLAX SEED OIL 1000 MG CAPS,34971,CDM,250,RC,43292055775,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % MDV 2.5 MG/ML SOLN,3498,CDM,250,RC,MHS1ML,HCPCS,409116001,NDC,facility,both,0.5,ME,,1.68,1.26,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % MDV 2.5 MG/ML SOLN,3498,CDM,636,RC,J0665,HCPCS,409116001,NDC,facility,both,0.5,ME,,0.3,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % MDV 2.5 MG/ML SOLN,3498,CDM,636,RC,FAMRXNC,HCPCS,409116001,NDC,facility,both,0.5,ME,,9.44,7.08,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % MDV 2.5 MG/ML SOLN,3498,CDM,250,RC,J0665,HCPCS,409116001,NDC,facility,both,0.5,ME,,0.34,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % MDV 5 MG/ML SOLN,3499,CDM,636,RC,J0665,HCPCS,409161050,NDC,facility,both,0.5,ME,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % MDV 5 MG/ML SOLN,3499,CDM,636,RC,FAMRXNC,HCPCS,143932910,NDC,facility,both,0.5,ME,,16.58,12.44,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % MDV 5 MG/ML SOLN,3499,CDM,636,RC,J0665,HCPCS,143932910,NDC,facility,both,0.5,ME,,18.25,13.69,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % MDV 5 MG/ML SOLN,3499,CDM,636,RC,J0665,HCPCS,63323046757,NDC,facility,both,0.5,ME,,26,19.5,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % MDV 5 MG/ML SOLN,3499,CDM,636,RC,J0665,HCPCS,409116301,NDC,facility,both,0.5,ME,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % MDV 5 MG/ML SOLN,3499,CDM,250,RC,FAMRXNC,HCPCS,409116301,NDC,facility,both,0.5,ME,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % MDV 5 MG/ML SOLN,3499,CDM,250,RC,MHS1ML,HCPCS,409116301,NDC,facility,both,0.5,ME,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % MDV 5 MG/ML SOLN,3499,CDM,636,RC,FAMRXNC,HCPCS,63323046757,NDC,facility,both,0.5,ME,,19.43,14.57,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % MDV 5 MG/ML SOLN,3499,CDM,250,RC,J0665,HCPCS,409116301,NDC,facility,both,0.5,ME,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 75 MG CAPS,35017,CDM,250,RC,47781047013,NDC,,,facility,both,2,UN,,21.35,16.01,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 75 MG CAPS,35017,CDM,250,RC,64380079901,NDC,,,facility,both,1,UN,,14.47,10.85,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 75 MG CAPS,35017,CDM,250,RC,72205004411,NDC,,,facility,both,1,UN,,11.6,8.7,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 75 MG CAPS,35017,CDM,250,RC,4080085,NDC,,,facility,both,1,UN,,34.5,25.88,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 75 MG CAPS,35017,CDM,250,RC,31722063231,NDC,,,facility,both,0.4,UN,,9.95,7.46,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 75 MG CAPS,35017,CDM,250,RC,31722063231,NDC,,,facility,both,1,UN,,13.15,9.86,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR 75 MG CAPS,35017,CDM,250,RC,47781047013,NDC,,,facility,both,1,UN,,26.4,19.8,,,,,,,,,,Gross Charge Type: Pharmacy
ENTACAPONE 200 MG TABS,35025,CDM,250,RC,27241004910,NDC,,,facility,both,0.5,UN,,8.03,6.02,,,,,,,,,,Gross Charge Type: Pharmacy
ENTACAPONE 200 MG TABS,35025,CDM,250,RC,27241004910,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
"Hc Computed Tomography, Thorax, Low Dose For Lung Cancer Screening, Without Contrast Material(S)",3507127101,CDM,350,RC,71271,HCPCS,,,facility,both,,,,326,244.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Whole Body-Multiple Myeloma,3507649701,CDM,350,RC,76497,HCPCS,,,facility,both,,,,650,487.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
VERAPAMIL 240 MG TBCR,35096,CDM,250,RC,75834015901,NDC,,,facility,both,1,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 240 MG TBCR,35096,CDM,250,RC,75834015901,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 2.5 MG TABS,35162,CDM,250,RC,43547035110,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 2.5 MG TABS,35162,CDM,250,RC,60687065621,NDC,,,facility,both,0.5,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 2.5 MG TABS,35162,CDM,250,RC,60687065621,NDC,,,facility,both,4,UN,,3.02,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 2.5 MG TABS,35162,CDM,250,RC,60687065621,NDC,,,facility,both,2,UN,,4.95,3.71,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 2.5 MG TABS,35162,CDM,250,RC,60687065621,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 10 MCG (400 UNITS) TABS,35197,CDM,250,RC,50268086315,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 10 MCG (400 UNITS) TABS,35197,CDM,250,RC,50268086315,NDC,,,facility,both,2,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 10 MCG (400 UNITS) TABS,35197,CDM,250,RC,904582360,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 10 MCG (400 UNITS) TABS,35197,CDM,250,RC,77333094810,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 10 MCG (400 UNITS) TABS,35197,CDM,250,RC,50268086315,NDC,,,facility,both,5,UN,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG TABS,35281,CDM,250,RC,31722070430,NDC,,,facility,both,4,UN,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG TABS,35281,CDM,250,RC,31722070430,NDC,,,facility,both,1,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG TABS,35281,CDM,250,RC,51079009303,NDC,,,facility,both,2,UN,,9.78,7.33,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG TABS,35281,CDM,250,RC,51079009303,NDC,,,facility,both,4,UN,,7.44,5.58,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG TABS,35281,CDM,250,RC,68084021501,NDC,,,facility,both,2,UN,,10.02,7.52,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG TABS,35281,CDM,250,RC,51079009303,NDC,,,facility,both,1,UN,,14.05,10.54,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG TABS,35281,CDM,250,RC,31722070430,NDC,,,facility,both,2,UN,,4.75,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 220 MG TABS,35283,CDM,250,RC,45802049071,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 220 MG TABS,35283,CDM,250,RC,45802049071,NDC,,,facility,both,2,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG TBCR,35390,CDM,250,RC,68462029201,NDC,,,facility,both,1,UN,,8.57,6.43,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG TBCR,35390,CDM,250,RC,68462029201,NDC,,,facility,both,1.5,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG TBCR,35390,CDM,250,RC,68462029201,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
RENAL MULTI-VITAMIN TABS,35474,CDM,250,RC,60258016001,NDC,,,facility,both,0.8,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
RENAL MULTI-VITAMIN TABS,35474,CDM,250,RC,60258016001,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
FAMCICLOVIR 500 MG TABS,35808,CDM,250,RC,93811956,NDC,,,facility,both,3,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
FAMCICLOVIR 500 MG TABS,35808,CDM,250,RC,93811956,NDC,,,facility,both,1,UN,,10.1,7.58,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 30 MG TBCR,35866,CDM,250,RC,406833062,NDC,,,facility,both,1,UN,,7.33,5.49,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 30 MG TBCR,35866,CDM,250,RC,904655861,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 4.25% LOW CALCIUM PERITONEAL DIALYSIS SOLN 483 MOSM/L SOLN,35878,CDM,250,RC,49230021250,NDC,,,facility,both,5000,ML,,62.05,46.54,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 4.25% LOW CALCIUM PERITONEAL DIALYSIS SOLN 483 MOSM/L SOLN,35878,CDM,250,RC,49230021250,NDC,,,facility,both,3400,ML,,48.45,36.34,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 4.25% LOW CALCIUM PERITONEAL DIALYSIS SOLN 483 MOSM/L SOLN,35878,CDM,250,RC,49230021250,NDC,,,facility,both,1000,ML,,27.25,20.44,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Eeg-Surgical Monitoring Per 15Min,3600000001,CDM,360,RC,,,,,facility,both,,,,263,197.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Or-Dental Cleaning,3600000003,CDM,360,RC,,,,,facility,both,,,,982,736.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incision And Drainage Pilonidal Cyst Complicated,3601008101,CDM,360,RC,10081,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Incision & Removal Foreign Body Subq Tiss Compl,3601012101,CDM,360,RC,10121,HCPCS,,,facility,both,,,,2967,2225.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incision & Removal Foreign Body Subq Tiss Compl,3601012101,CDM,360,RC,10121,HCPCS,,,facility,both,,,,2967,2225.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Dbrdmt W/Rmvl Fm Fx And /Dislc Skin And Subq Tissus,3601101001,CDM,360,RC,11010,HCPCS,,,facility,both,,,,678,508.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Debridement W/Rmvl Fm Fx/Dislc Skn Subq T/M/F Musc,3601101101,CDM,360,RC,11011,HCPCS,,,facility,both,,,,4363,3272.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Deb Skin Bone At Fx Site,3601101201,CDM,360,RC,11012,HCPCS,,,facility,both,,,,2047,1535.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc H-F-Nk-Sp B9+Marg 0.5/<,3601142001,CDM,360,RC,11420,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc H-F-Nk-Sp B9+Marg 0.5/<,3601142001,CDM,360,RC,11420,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Exc H-F-Nk-Sp B9+Marg 0.5/<,3601142001,CDM,360,RC,11420,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc H-F-Nk-Sp B9+Marg 1.1-2,3601142201,CDM,360,RC,11422,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc H-F-Nk-Sp B9+Marg 1.1-2,3601142201,CDM,360,RC,11422,HCPCS,,,facility,both,,,,1740,1305,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Excision, Benign Lesion Including Margins, Except Skin Tag (Unless Listed Elsewhere), Scalp, Neck",3601142601,CDM,360,RC,11426,HCPCS,,,facility,both,,,,2998,2248.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc S/N/H/F/G Mal+Mrg 3.1-4,3601162401,CDM,360,RC,11624,HCPCS,,,facility,both,,,,2126,1594.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc S/N/H/F/G Mal+Mrg 3.1-4,3601162401,CDM,360,RC,11624,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Biopsy Nail Unit,3601175501,CDM,360,RC,11755,HCPCS,,,facility,both,,,,751,563.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or External Genitalia, 20.1 Cm To 30.0 Cm",3601204601,CDM,360,RC,12046,HCPCS,,,facility,both,,,,2427,1820.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or External Genitalia, 20.1 Cm To 30.0 Cm",3601204601,CDM,360,RC,12046,HCPCS,,,facility,both,,,,549,411.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Secondary Closure Surg Wound/Dehsn Extsv/Complic,3601316001,CDM,360,RC,13160,HCPCS,,,facility,both,,,,7118,5338.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Adjacent Tissue Transfer Or Rearrangemt 10Sqcm Or Less,3601404001,CDM,360,RC,14040,HCPCS,,,facility,both,,,,2773,2079.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Adjacent Tissue Transfer Or Rearrangemt 10Sqcm Or Less,3601404001,CDM,360,RC,14040,HCPCS,,,facility,both,,,,2064,1548,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Full Thick Gft Chin/Ax/Ft 20,3601524001,CDM,360,RC,15240,HCPCS,,,facility,both,,,,2539,1904.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Skin Full Graft Add'l 20 Sq Cm,3601524101,CDM,360,RC,15241,HCPCS,,,facility,both,,,,1058,793.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Frmj Dir/Tube Pedcl W/Wotr Fh/Ch/Ch/M/N/Ax/G/H/F,3601557401,CDM,360,RC,15574,HCPCS,,,facility,both,,,,4214,3160.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Excision Excessive Skin And Subq Tissue Arm,3601583601,CDM,360,RC,15836,HCPCS,,,facility,both,,,,4539,3404.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Muscle Superficial,3602020001,CDM,360,RC,20200,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Application Uniplane External Fixation System,3602069001,CDM,360,RC,20690,HCPCS,,,facility,both,,,,16801,12600.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Of Bone For Graft,3602090201,CDM,360,RC,20902,HCPCS,,,facility,both,,,,9098,6823.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Tumor Soft Tiss Face And Scalp Subfascial Less Than2Cm,3602101301,CDM,360,RC,21013,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Tumor Soft Tiss Face And Scalp Subfascial 2 Cm/Greater Than,3602101401,CDM,360,RC,21014,HCPCS,,,facility,both,,,,3592,2694,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Tumor Soft Tiss Face And Scalp Subfascial 2 Cm/Greater Than,3602101401,CDM,360,RC,21014,HCPCS,,,facility,both,,,,2484,1863,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Excision, Tumor, Soft Tissue Back/Flank,Subcutaneous;3 Cm >",3602193101,CDM,360,RC,21931,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Excision, Tumor, Soft Tissue Back/Flank,Subcutaneous;3 Cm >",3602193101,CDM,360,RC,21931,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Excision Tumor Soft Tissue Shoulder Subq 3 Cm,3602307101,CDM,360,RC,23071,HCPCS,,,facility,both,,,,1566,1174.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Ex Arm/Elbow Tum Deep < 5 Cm,3602407601,CDM,360,RC,24076,HCPCS,,,facility,both,,,,6152,4614,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Foreign Body Upper Arm/Elbow Deep,3602420101,CDM,360,RC,24201,HCPCS,,,facility,both,,,,10313,7734.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Foreign Body Upper Arm/Elbow Deep,3602420101,CDM,360,RC,24201,HCPCS,,,facility,both,,,,2745,2058.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Incis Exten Tendon Sheath Wris,3602500001,CDM,360,RC,25000,HCPCS,,,facility,both,,,,3346,2509.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incise Flexor Tendon Sheath. Wrst,3602500101,CDM,360,RC,25001,HCPCS,,,facility,both,,,,6856,5142,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drainage Of Forearm Lesion,3602502801,CDM,360,RC,25028,HCPCS,,,facility,both,,,,3252,2439,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Tumor Soft Tiss Forearm And/Wrist Subq 3Cm Or More,3602507101,CDM,360,RC,25071,HCPCS,,,facility,both,,,,2377,1782.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Exc Tumor Soft Tiss Forearm And/Wrist Subq 3Cm Or More,3602507101,CDM,360,RC,25071,HCPCS,,,facility,both,,,,1524,1143,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Tumor Soft Tissue Forearm/Wrist Subq Less Than 3Cm,3602507501,CDM,360,RC,25075,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Exc Tumor Soft Tissue Forearm/Wrist Subq Less Than 3Cm,3602507501,CDM,360,RC,25075,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Excision Lesion Tendon Sheath Forearm And/Wrist,3602511001,CDM,360,RC,25110,HCPCS,,,facility,both,,,,6424,4818,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Ganglion Wrist Prim,3602511101,CDM,360,RC,25111,HCPCS,,,facility,both,,,,3278,2458.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Ganglion Wrist Recurrent,3602511201,CDM,360,RC,25112,HCPCS,,,facility,both,,,,2818,2113.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rad Exc Bursa Synva Wrst/F/Arm Tdn Shths Xtnsrs,3602511601,CDM,360,RC,25116,HCPCS,,,facility,both,,,,6860,5145,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Excis Synov Wrist, Extens Tendon",3602511801,CDM,360,RC,25118,HCPCS,,,facility,both,,,,3910,2932.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Excis/Curet Benig Bone Les Rad/Ulna,3602512001,CDM,360,RC,25120,HCPCS,,,facility,both,,,,4485,3363.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Partial Excision Bone Radius,3602515101,CDM,360,RC,25151,HCPCS,,,facility,both,,,,6365,4773.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Of Carpal Bone,3602521001,CDM,360,RC,25210,HCPCS,,,facility,both,,,,5518,4138.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Of Prox Row Carpal Bones,3602521501,CDM,360,RC,25215,HCPCS,,,facility,both,,,,9396,7047,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Primary Repair Of Tendon Or Muscle Of Palm Side Of Forearm Or Wrist,3602526001,CDM,360,RC,25260,HCPCS,,,facility,both,,,,8558,6418.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repair Forearm Tendon/Muscle,3602527001,CDM,360,RC,25270,HCPCS,,,facility,both,,,,5520,4140,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lngth/Shrt Flxr/Xtnsr Tendon F/Arm/Wrist Each Tendon,3602528001,CDM,360,RC,25280,HCPCS,,,facility,both,,,,3795,2846.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incise Wrist/Forearm Tendon,3602529001,CDM,360,RC,25290,HCPCS,,,facility,both,,,,3901,2925.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Release Wrist/Forearm Tendon,3602529501,CDM,360,RC,25295,HCPCS,,,facility,both,,,,3901,2925.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Transplant Forearm/Wrist Tendon,3602531001,CDM,360,RC,25310,HCPCS,,,facility,both,,,,4364,3273,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tdn Trnsplj/Tr Flxr/Xtnsr F/Arm And/Wrst 1/Tdn Gr,3602531201,CDM,360,RC,25312,HCPCS,,,facility,both,,,,8988,6741,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repair/Revise Wrist Joint,3602532001,CDM,360,RC,25320,HCPCS,,,facility,both,,,,7814,5860.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthroplas Interposit-Carpomet,3602544701,CDM,360,RC,25447,HCPCS,,,facility,both,,,,7192,5394,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Optx Dstl Radl X-Artic Fx/Epiphysl Sep,3602560701,CDM,360,RC,25607,HCPCS,,,facility,both,,,,12803,9602.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Optx Dstl Radl I-Artic Fx/Epiphysl Sep 2 Frag,3602560801,CDM,360,RC,25608,HCPCS,,,facility,both,,,,14849,11136.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Optx Dstl Radl I-Artic Fx/Epiphysl Sep 3 Frag,3602560901,CDM,360,RC,25609,HCPCS,,,facility,both,,,,15539,11654.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Open Treatment Of Carpal Scaphoid (Navicular) Fracture, Includes Internal Fixation, When Performe",3602562801,CDM,360,RC,25628,HCPCS,,,facility,both,,,,24715,18536.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrodesis Wrist Limited W/O Bone Graft,3602582001,CDM,360,RC,25820,HCPCS,,,facility,both,,,,9374,7030.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drain Tendon Sheath/Digit &/Pa,3602602001,CDM,360,RC,26020,HCPCS,,,facility,both,,,,3225,2418.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Treat Hand Bone Lesion,3602603401,CDM,360,RC,26034,HCPCS,,,facility,both,,,,2185,1638.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrt Expl Drg/Rmvl Loose/Fb Mtcarphlngl Jt Ea,3602607501,CDM,360,RC,26075,HCPCS,,,facility,both,,,,5010,3757.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrot W/Explor/Drain Ip Jt,3602608001,CDM,360,RC,26080,HCPCS,,,facility,both,,,,2070,1552.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Hand Les Sc 15 Cm/>,3602611101,CDM,360,RC,26111,HCPCS,,,facility,both,,,,3406,2554.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Hand Tum Deep 15 Cm/>,3602611301,CDM,360,RC,26113,HCPCS,,,facility,both,,,,2961,2220.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Tumor Hand/Finger Subq,3602611501,CDM,360,RC,26115,HCPCS,,,facility,both,,,,2150,1612.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Tumor Hand/Finger Deep/Im,3602611601,CDM,360,RC,26116,HCPCS,,,facility,both,,,,2128,1596,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rad Rescj Tum Soft Tissue Hand/Finger 3 Cm/Greater Than,3602611801,CDM,360,RC,26118,HCPCS,,,facility,both,,,,8774,6580.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fasciect Palm W/Wo Z-Plasty/Gf,3602612101,CDM,360,RC,26121,HCPCS,,,facility,both,,,,4232,3174,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fasciect Part Palm W/Rel 1 Dig,3602612301,CDM,360,RC,26123,HCPCS,,,facility,both,,,,4714,3535.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fasciect Part Palm W/Rel Ea A,3602612501,CDM,360,RC,26125,HCPCS,,,facility,both,,,,2513,1884.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Synovect Flex Tendon Palm/Fing,3602614501,CDM,360,RC,26145,HCPCS,,,facility,both,,,,2300,1725,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Les Tendon Sheath Hand/Fin,3602616001,CDM,360,RC,26160,HCPCS,,,facility,both,,,,2530,1897.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Excision/Curettage Cyst/Tumor Metacarpal,3602620001,CDM,360,RC,26200,HCPCS,,,facility,both,,,,5695,4271.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Excis Benign Bone Lesn,Phalanx",3602621001,CDM,360,RC,26210,HCPCS,,,facility,both,,,,1850,1387.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Remove/Graft Finger Lesion,3602621501,CDM,360,RC,26215,HCPCS,,,facility,both,,,,3254,2440.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Partial Removal Of Hand Bone,3602623001,CDM,360,RC,26230,HCPCS,,,facility,both,,,,4485,3363.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Part Remv Bone,Prox/Mid Phalanx",3602623501,CDM,360,RC,26235,HCPCS,,,facility,both,,,,2185,1638.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Radical Resection Tumor Metacarpal,3602625001,CDM,360,RC,26250,HCPCS,,,facility,both,,,,11376,8532,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Remov Implnt From Finger/Hand,3602632001,CDM,360,RC,26320,HCPCS,,,facility,both,,,,2242,1681.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repr Flex Tendon Prim/2Nd Ea,3602635001,CDM,360,RC,26350,HCPCS,,,facility,both,,,,3680,2760,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repr Flex Tend-Dig Sheath Pri,3602635601,CDM,360,RC,26356,HCPCS,,,facility,both,,,,4299,3224.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rpr/Advmnt Flxr Tdn Zone 2 W/Fr Graft Ea Tendon,3602635801,CDM,360,RC,26358,HCPCS,,,facility,both,,,,13082,9811.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tendon Finger/Hand Repair,3602637001,CDM,360,RC,26370,HCPCS,,,facility,both,,,,3680,2760,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repair/Graft Finger Tendon,3602642001,CDM,360,RC,26420,HCPCS,,,facility,both,,,,4174,3130.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rpr Xtnsr Tdn Cntrl Slip Tiss W/Lat Band Ea Fngr,3602642601,CDM,360,RC,26426,HCPCS,,,facility,both,,,,5297,3972.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repair Extensor Tendon Distal Insertion W/O Grf,3602643301,CDM,360,RC,26433,HCPCS,,,facility,both,,,,7320,5490,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Realignment Of Tendons,3602643701,CDM,360,RC,26437,HCPCS,,,facility,both,,,,3928,2946,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Release Palm Finger Tendon,3602644001,CDM,360,RC,26440,HCPCS,,,facility,both,,,,2294,1720.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tenlysis Exten Tend Hand/Fingr,3602644501,CDM,360,RC,26445,HCPCS,,,facility,both,,,,3416,2562,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fusion Of Finger Tendons,3602647101,CDM,360,RC,26471,HCPCS,,,facility,both,,,,3416,2562,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tendon Transfer Transplant Carp/Mtcrpl Graft,3602648301,CDM,360,RC,26483,HCPCS,,,facility,both,,,,8861,6645.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Transfer/Transplant Tendon Palmar W/Graft Each,3602648901,CDM,360,RC,26489,HCPCS,,,facility,both,,,,7983,5987.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rcnstj Tendon Pulley Each W/Local Tissues Spx,3602650001,CDM,360,RC,26500,HCPCS,,,facility,both,,,,10179,7634.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Release Knuckle Contracture,3602652001,CDM,360,RC,26520,HCPCS,,,facility,both,,,,4440,3330,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Release Finger Contracture,3602652501,CDM,360,RC,26525,HCPCS,,,facility,both,,,,3795,2846.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Revise Knuckle With Implant,3602653101,CDM,360,RC,26531,HCPCS,,,facility,both,,,,9258,6943.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Revise Finger Joint,3602653501,CDM,360,RC,26535,HCPCS,,,facility,both,,,,5175,3881.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthroplasty Ip Jt W/Prosth E,3602653601,CDM,360,RC,26536,HCPCS,,,facility,both,,,,8050,6037.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repr Collat Ligamnt Mcp/Ip Jt,3602654001,CDM,360,RC,26540,HCPCS,,,facility,both,,,,3416,2562,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rpr Non-Union Mtcrpl/Phalanx,3602654601,CDM,360,RC,26546,HCPCS,,,facility,both,,,,2750,2062.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rpr And Rcnstj Finger Volar Plate Interphalangeal,3602654801,CDM,360,RC,26548,HCPCS,,,facility,both,,,,13082,9811.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Correct Metacarpal Flaw,3602656501,CDM,360,RC,26565,HCPCS,,,facility,both,,,,4746,3559.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repair Muscles Of Hand,3602659101,CDM,360,RC,26591,HCPCS,,,facility,both,,,,2425,1818.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Release Muscles Of Hand,3602659301,CDM,360,RC,26593,HCPCS,,,facility,both,,,,3957,2967.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Closed Rx Metacarpal Fx,Percut",3602660801,CDM,360,RC,26608,HCPCS,,,facility,both,,,,8546,6409.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Open Tx Metacarpal Fx Sngl W/W,3602661501,CDM,360,RC,26615,HCPCS,,,facility,both,,,,9496,7122,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Treat Thumb Fracture W/Manip,3602665001,CDM,360,RC,26650,HCPCS,,,facility,both,,,,4226,3169.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Percutaneous Skeletal Fixation Of Carpometacarpal Dislocation, Other Than Thumb, With Manipulatio",3602667601,CDM,360,RC,26676,HCPCS,,,facility,both,,,,11376,8532,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Optx Carp/Mtcrpl Dislc Thmb Cplx Mlt/Dlyd Rdctj,3602668601,CDM,360,RC,26686,HCPCS,,,facility,both,,,,8695,6521.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Open Treatment Metacarpophalangeal Dislocation,3602671501,CDM,360,RC,26715,HCPCS,,,facility,both,,,,7357,5517.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Percut Fixa Fx Prox/Mid W/Mani,3602672701,CDM,360,RC,26727,HCPCS,,,facility,both,,,,3421,2565.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Open Tx Phalangeal Shaft Fracture Prox, Middle Ea",3602673501,CDM,360,RC,26735,HCPCS,,,facility,both,,,,4554,3415.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Open Tx Articular Fracture Mcp/Ip Joint Ea,3602674601,CDM,360,RC,26746,HCPCS,,,facility,both,,,,4140,3105,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pin Finger Fracture Each,3602675601,CDM,360,RC,26756,HCPCS,,,facility,both,,,,4278,3208.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Treat Finger Fracture Ea,3602676501,CDM,360,RC,26765,HCPCS,,,facility,both,,,,4278,3208.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Treat Finger Fracture Ea,3602676501,CDM,360,RC,26765,HCPCS,,,facility,both,,,,5053,3789.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Treat Finger Dislocation,3602678501,CDM,360,RC,26785,HCPCS,,,facility,both,,,,4400,3300,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Treat Finger Dislocation,3602678501,CDM,360,RC,26785,HCPCS,,,facility,both,,,,4400,3300,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Arthrd Carp/Mtcrpl Jt Dgt Other Than Thumb Each,3602684301,CDM,360,RC,26843,HCPCS,,,facility,both,,,,5739,4304.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrodesis Mcp Jt W/Wo Int Fi,3602685001,CDM,360,RC,26850,HCPCS,,,facility,both,,,,4140,3105,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fusion Of Finger Joint,3602686001,CDM,360,RC,26860,HCPCS,,,facility,both,,,,4163,3122.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fusion Of Finger Joint, Each Additional Joint",3602686101,CDM,360,RC,26861,HCPCS,,,facility,both,,,,2857,2142.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Fusion/Graft Of Finger Joint,3602686201,CDM,360,RC,26862,HCPCS,,,facility,both,,,,5569,4176.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amputa Finger Any Jt W/Advanc,3602695201,CDM,360,RC,26952,HCPCS,,,facility,both,,,,3747,2810.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Suture Quadriceps/Hamstring Rupture Primary,3602738501,CDM,360,RC,27385,HCPCS,,,facility,both,,,,19018,14263.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Repair, Dislocating Peroneal Tendons; With Fibular Osteotomy",3602767601,CDM,360,RC,27676,HCPCS,,,facility,both,,,,9630,7222.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrt W/Expl Drg/Rmvl Loose/Fb Ntrtrsl/Tars Jt,3602802001,CDM,360,RC,28020,HCPCS,,,facility,both,,,,6163,4622.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ostc Compl All Metar Heads W/Prtl Prox Phalangc,3602811401,CDM,360,RC,28114,HCPCS,,,facility,both,,,,7442,5581.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Foreign Body Foot Complicated,3602819301,CDM,360,RC,28193,HCPCS,,,facility,both,,,,6085,4563.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Foreign Body Foot Complicated,3602819301,CDM,360,RC,28193,HCPCS,,,facility,both,,,,6085,4563.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Osteotomy Tarsal Bones Oth/Thn Calcaneus/Talus,3602830401,CDM,360,RC,28304,HCPCS,,,facility,both,,,,5917,4437.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rcnstj Angular Dfrm Toe Soft Tiss Px Only,3602831301,CDM,360,RC,28313,HCPCS,,,facility,both,,,,4822,3616.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Surgical Arthroscopy Shoulder Repair Slap Lesion,3602980701,CDM,360,RC,29807,HCPCS,,,facility,both,,,,8322,6241.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Endo Wrst Surg-Releas Trns Car,3602984801,CDM,360,RC,29848,HCPCS,,,facility,both,,,,3966,2974.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Endo Wrst Surg-Releas Trns Car,3602984801_50,CDM,360,RC,29848,HCPCS,,,facility,both,,,50,5949,4461.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Abltj Soft Tis Inferior Turbinates Uni/Bi Supfc,3603080101,CDM,360,RC,30801,HCPCS,,,facility,both,,,,1454,1090.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Unlisted Procedure Trachea Bronchi,3603189901,CDM,360,RC,31899,HCPCS,,,facility,both,,,,819,614.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Unlisted Procedure Trachea Bronchi,3603189901,CDM,360,RC,31899,HCPCS,,,facility,both,,,,819,614.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Creation Of Pericardial Window Or Partial Resection For Drainage,3603302501,CDM,360,RC,33025,HCPCS,,,facility,both,,,,1700,1275,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Replace Aortic Valve Open Axillry Artry Approach,3603336301,CDM,360,RC,33363,HCPCS,,,facility,both,,,,3293,2469.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Subclv Artery Conduit Insert,3603471601,CDM,360,RC,34716,HCPCS,,,facility,both,,,,4600,3450,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Venipuncture, Younger Than Age 3 Years, Qhp Skill Femral/Juglar Vein",3603640001,CDM,360,RC,36400,HCPCS,,,facility,both,,,,213,159.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Rmvl Tun Cvc W/O Subq Port/Pmp,3603658901,CDM,360,RC,36589,HCPCS,,,facility,both,,,,2689,2016.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ligatn Thor Duct,Thor Approach",3603838101,CDM,360,RC,38381,HCPCS,,,facility,both,,,,12259,9194.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Access Thoracic Lymph Duct,3603879401,CDM,360,RC,38794,HCPCS,,,facility,both,,,,2248,1686,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Excision Lingual Frenum Frenectomy,3604111501,CDM,360,RC,41115,HCPCS,,,facility,both,,,,1725,1293.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dilation Esophagus Guide Wire,3604345301,CDM,360,RC,43453,HCPCS,,,facility,both,,,,2496,1872,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Laps Surg Trnsxj Vagus Nrv Truncal,3604365101,CDM,360,RC,43651,HCPCS,,,facility,both,,,,13031,9773.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Laps Surg Trnsxj Vagus Nrv Slctv/Hily Slctv,3604365201,CDM,360,RC,43652,HCPCS,,,facility,both,,,,13031,9773.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exploratory Of Abdomen,3604900001,CDM,360,RC,49000,HCPCS,,,facility,both,,,,1888,1416,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Plmt Nephroureteral Cath Prq New Access Rs&I,3605043301,CDM,360,RC,50433,HCPCS,,,facility,both,,,,9977,7482.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Dil Urethra Stric,Male,Initial",3605360001,CDM,360,RC,53600,HCPCS,,,facility,both,,,,674,505.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Destruction Lesions Vulva Simple,3605650101,CDM,360,RC,56501,HCPCS,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/O Img Gdn,3606232401,CDM,360,RC,62324,HCPCS,,,facility,both,,,,2746,2059.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/O Img Gdn,3606232401,CDM,360,RC,62324,HCPCS,,,facility,both,,,,2746,2059.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Impltj Revj/Rpsg Ithcl/Edrl Cath Pmp W/O Lam,3606235001,CDM,360,RC,62350,HCPCS,,,facility,both,,,,9615,7211.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Revision Or Removal Of Peripheral Neurostimulator Electrode Array,3606458501,CDM,360,RC,64585,HCPCS,,,facility,both,,,,5645,4233.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Revise Finger/Toe Nerve,3606470201,CDM,360,RC,64702,HCPCS,,,facility,both,,,,2245,1683.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuroplasty Ulnar Nerv @ Elbo,3606471801,CDM,360,RC,64718,HCPCS,,,facility,both,,,,4232,3174,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuroplasty Ulnar Nerv @ Wris,3606471901,CDM,360,RC,64719,HCPCS,,,facility,both,,,,2300,1725,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neuroplasty Median @ Carpal T,3606472101,CDM,360,RC,64721,HCPCS,,,facility,both,,,,3567,2675.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Remove Skin Nerve Lesion,3606477401,CDM,360,RC,64774,HCPCS,,,facility,both,,,,6607,4955.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Remove Digit Nerve Lesion,3606477601,CDM,360,RC,64776,HCPCS,,,facility,both,,,,6602,4951.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Excision Neuroma Digital Nrv Ea Addl Digit,3606477801,CDM,360,RC,64778,HCPCS,,,facility,both,,,,3541,2655.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Neuroma Hand/Foot Xcp Digital Nerve,3606478201,CDM,360,RC,64782,HCPCS,,,facility,both,,,,2807,2105.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc Neurofibroma/Neurolemmoma Cutan Nrv,3606478801,CDM,360,RC,64788,HCPCS,,,facility,both,,,,7075,5306.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Suture Digital Nerv Hand/Ft 1,3606483101,CDM,360,RC,64831,HCPCS,,,facility,both,,,,5568,4176,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Suture Digital Nerv Hand/Ft E,3606483201,CDM,360,RC,64832,HCPCS,,,facility,both,,,,4738,3553.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Suture 1 Nerve Median Motor Thenar,3606483501,CDM,360,RC,64835,HCPCS,,,facility,both,,,,7738,5803.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repair/Transpose Nerve,3606485601,CDM,360,RC,64856,HCPCS,,,facility,both,,,,11284,8463,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nerve Repair W/Allograft,3606491001,CDM,360,RC,64910,HCPCS,,,facility,both,,,,13080,9810,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nerve Repair W/Nerve Allograft First Strand,3606491201,CDM,360,RC,64912,HCPCS,,,facility,both,,,,11283,8462.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nerve Repair W/Nerve Allograft Ea Addl Strand,3606491301,CDM,360,RC,64913,HCPCS,,,facility,both,,,,1129,846.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incisional Biopsy Eyelid Skin And Lid Margin,3606781001,CDM,360,RC,67810,HCPCS,,,facility,both,,,,282,211.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Sutr Wnd Eyelid/Margin/Tarsus/Conjunc Full Thick,3606793501,CDM,360,RC,67935,HCPCS,,,facility,both,,,,7861,5895.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sutr Wnd Eyelid/Margin/Tarsus/Conjunc Full Thick,3606793501,CDM,360,RC,67935,HCPCS,,,facility,both,,,,7861,5895.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Fine Needle Aspiration Biopsy, Without Imaging Guidance; Each Additional Lesion (List Separately",3611000401,CDM,361,RC,10004,HCPCS,,,facility,both,,,,707,530.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
BISACODYL 5 MG TBEC,36111,CDM,250,RC,904640761,NDC,,,facility,both,3,UN,,2.18,1.64,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 5 MG TBEC,36111,CDM,250,RC,904640761,NDC,,,facility,both,2,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 5 MG TBEC,36111,CDM,250,RC,904640761,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Removal Sutures/Staples Requiring Anesthesia,3611585101,CDM,361,RC,15851,HCPCS,,,facility,both,,,,6717,5037.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Sutures/Staples Requiring Anesthesia,3611585101,CDM,361,RC,15851,HCPCS,,,facility,both,,,,6717,5037.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Biopsy, Soft Tissue Of Upper Arm Or Elbow Area; Superficial",3612406501,CDM,361,RC,24065,HCPCS,,,facility,both,,,,5965,4473.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Open Tx Carpal Bone Fracture Oth/Thn Scaphoid Ea,3612564501,CDM,361,RC,25645,HCPCS,,,facility,both,,,,8558,6418.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Capsulodesis Mtcarphlngl Joint Single Digit,3612651601,CDM,361,RC,26516,HCPCS,,,facility,both,,,,8558,6418.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Open Treatment Of Carpometacarpal Fracture Dislocation, Thumb (Bennett Fracture), Includes Intern",3612666501,CDM,361,RC,26665,HCPCS,,,facility,both,,,,13082,9811.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Open Tx Carpometacarpal Dislocate Not Thumb,3612668501,CDM,361,RC,26685,HCPCS,,,facility,both,,,,7442,5581.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tenotomy, Percutaneous, Achilles Tendon (Separate Procedure), Local Anesthesia",3612760501,CDM,361,RC,27605,HCPCS,,,facility,both,,,,5581,4185.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Core Needle Biopsy, Lung Or Mediastinum, Percutaneous, Including Imaging Guidance, When Performed",3613240801,CDM,361,RC,32408,HCPCS,,,facility,both,,,,2140,1605,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Abhc Ablation Ther One Or More Pulm Tumors Perq Cryoablationlate Pulm Tumor Perq Crybl,3613299401,CDM,361,RC,32994,HCPCS,,,facility,both,,,,22918,17188.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pericardiocentesis W/Img Guidance When Performed,3613301601,CDM,361,RC,33016,HCPCS,,,facility,both,,,,1659,1244.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Endovenous Ablation Therapy Incompetent Vein, Transcatheter Delivery Of Chemical Adhesive Remote",3613648201,CDM,361,RC,36482,HCPCS,,,facility,both,,,,6104,4578,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Endovenous Ablation Therapy Incomp Vein Transcatheter Chemical Adhesive Remove Access Site,All Im",3613648301,CDM,361,RC,36483,HCPCS,,,facility,both,,,,611,458.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Ligation Major Artery Extremity,3613761801,CDM,361,RC,37618,HCPCS,,,facility,both,,,,3634,2725.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ligation Major Artery Extremity,3613761801,CDM,361,RC,37618,HCPCS,,,facility,both,,,,3634,2725.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Stab Phlebectomy Of Varicose Veins 1 Extremity 10-20 Stab Incisions,3613776501,CDM,361,RC,37765,HCPCS,,,facility,both,,,,11455,8591.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Unlisted Procedure Vascular Surgery: Fibrin Sheath Disruption,3613779901,CDM,361,RC,37799,HCPCS,,,facility,both,,,,2689,2016.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc  Instlj Ther Agent Renal Pelvis &/Ureter Via Tub,3615039101,CDM,361,RC,50391,HCPCS,,,facility,both,,,,1746,1309.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Colposcopy Cervix Endocervical Curettage,3615745601,CDM,361,RC,57456,HCPCS,,,facility,both,,,,306,229.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Injection(S), Anesthetic Agent(S) And/Or Steroid; Axillary Nerve, Including Imaging Guidance, Whe",3616441701,CDM,361,RC,64417,HCPCS,,,facility,both,,,,3317,2487.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Bronchoscopy, Rigid Or Flexible, Diagnostic With Cell Washing(S) When Performed, With Computer-Assis",361C750901,CDM,361,RC,C7509,HCPCS,,,facility,both,,,,5938,4453.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
CETAPHIL MOISTURIZING CREA,3624,CDM,250,RC,299391756,NDC,,,facility,both,1,GR,,21.25,15.94,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-POLYMYXIN B SOLN 1 ML AMPULE,36361,CDM,250,RC,MHS1ML,HCPCS,39822120102,NDC,facility,both,1,ML,,20.02,15.02,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE 200 MG TABS,3638,CDM,250,RC,46017001840,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE 200 MG TABS,3638,CDM,250,RC,70677002101,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE 200 MG TABS,3638,CDM,250,RC,46017001840,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 150 MG TABS,36392,CDM,250,RC,16714069211,NDC,,,facility,both,1,UN,,11.1,8.32,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 150 MG TABS,36392,CDM,250,RC,59762501701,NDC,,,facility,both,1,UN,,12.7,9.52,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,68084077595,NDC,,,facility,both,4,UN,,3.98,2.98,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,50268075915,NDC,,,facility,both,2,UN,,4.56,3.42,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,60505025103,NDC,,,facility,both,2,UN,,4.05,3.04,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,72789032630,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,50268075915,NDC,,,facility,both,1,UN,,8.46,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,60505025103,NDC,,,facility,both,3,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,68084077595,NDC,,,facility,both,2,UN,,6,4.5,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,60505025103,NDC,,,facility,both,4,UN,,2.28,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,50268075915,NDC,,,facility,both,3,UN,,4.03,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,68084077595,NDC,,,facility,both,1,UN,,9.82,7.37,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,68084077595,NDC,,,facility,both,0.5,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,72789032630,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,72789032630,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,68084077595,NDC,,,facility,both,3,UN,,4.67,3.5,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 2 MG TABS,36463,CDM,250,RC,60505025103,NDC,,,facility,both,1,UN,,3.62,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 100 MG/ML SOLN 20 ML VIAL,36487,CDM,636,RC,J9100,HCPCS,63323012020,NDC,facility,both,100,ME,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG TABS,36488,CDM,250,RC,904726361,NDC,,,facility,both,4,UN,,3.29,2.47,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG TABS,36488,CDM,250,RC,904726361,NDC,,,facility,both,0.5,UN,,2.05,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG TABS,36488,CDM,250,RC,904726361,NDC,,,facility,both,1,UN,,9.01,6.76,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG TABS,36488,CDM,250,RC,904726361,NDC,,,facility,both,1.5,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG TABS,36488,CDM,250,RC,62756018488,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG TABS,36488,CDM,250,RC,904726361,NDC,,,facility,both,3,UN,,3.84,2.88,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG TABS,36488,CDM,250,RC,904726361,NDC,,,facility,both,2,UN,,5.21,3.91,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 600 MG TABS,36489,CDM,250,RC,60687073311,NDC,,,facility,both,1,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 600 MG TABS,36489,CDM,250,RC,60687073311,NDC,,,facility,both,2,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM HYDROXIDE-MAGNESIUM CARBONATE 95-358 MG/15ML SUSP,36492,CDM,250,RC,904772714,NDC,,,facility,both,15,ML,,5.4,4.05,,,,,,,,,,Gross Charge Type: Pharmacy
EXEMESTANE 25 MG TABS,36512,CDM,250,RC,59651051630,NDC,,,facility,both,1,UN,,48.85,36.64,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ CPCR,36574,CDM,250,RC,50268067113,NDC,,,facility,both,3,UN,,3.92,2.94,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ CPCR,36574,CDM,250,RC,50268067113,NDC,,,facility,both,6,UN,,2.58,1.94,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ CPCR,36574,CDM,250,RC,50268067113,NDC,,,facility,both,4,UN,,3.26,2.45,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ CPCR,36574,CDM,250,RC,50268067113,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ CPCR,36574,CDM,250,RC,53746054201,NDC,,,facility,both,1,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ CPCR,36574,CDM,250,RC,50268067113,NDC,,,facility,both,2,UN,,5.22,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG TABS,36587,CDM,250,RC,65862060330,NDC,,,facility,both,1,UN,,13.74,10.31,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG TABS,36587,CDM,250,RC,50268057613,NDC,,,facility,both,1,UN,,23.85,17.89,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG TABS,36587,CDM,250,RC,55111011230,NDC,,,facility,both,1,UN,,13.75,10.31,,,,,,,,,,Gross Charge Type: Pharmacy
CALAMINE-ZINC OXIDE 8 %-8 % LOTN 177 ML BOTTLE,3666,CDM,250,RC,MHS1ML,HCPCS,49348001134,NDC,facility,both,1,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 125 MCG CAPS,36817,CDM,250,RC,69452013117,NDC,,,facility,both,1,UN,,11.15,8.36,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 125 MCG CAPS,36817,CDM,250,RC,69452013117,NDC,,,facility,both,2,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 250 MCG CAPS,36818,CDM,250,RC,69452013217,NDC,,,facility,both,1,UN,,11.15,8.36,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 500 MCG CAPS,36819,CDM,250,RC,69582043,NDC,,,facility,both,1,UN,,28.95,21.71,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5ML LIQD,36978,CDM,250,RC,121148800,NDC,,,facility,both,30,ML,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5ML LIQD,36978,CDM,250,RC,121148800,NDC,,,facility,both,40,ML,,2.48,1.86,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5ML LIQD,36978,CDM,250,RC,121148800,NDC,,,facility,both,10,ML,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5ML LIQD,36978,CDM,250,RC,121148800,NDC,,,facility,both,20,ML,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5ML LIQD,36978,CDM,250,RC,121148800,NDC,,,facility,both,5,ML,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5ML LIQD,36978,CDM,250,RC,121174400,NDC,,,facility,both,30,ML,,1.95,1.46,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5ML LIQD,36978,CDM,250,RC,121148800,NDC,,,facility,both,60,ML,,2.01,1.51,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG TABS,36979,CDM,250,RC,60687071101,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG TABS,36979,CDM,250,RC,68462013701,NDC,,,facility,both,2,UN,,3.95,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG TABS,36979,CDM,250,RC,60687071101,NDC,,,facility,both,3,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG TABS,36979,CDM,250,RC,68462013701,NDC,,,facility,both,4,UN,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG TABS,36979,CDM,250,RC,68462013701,NDC,,,facility,both,3,UN,,2.87,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG TABS,36979,CDM,250,RC,60687071101,NDC,,,facility,both,2,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG TABS,36979,CDM,250,RC,60687071101,NDC,,,facility,both,4,UN,,2.71,2.03,,,,,,,,,,Gross Charge Type: Pharmacy
Hc General Anesthesia 15Min,3700000001,CDM,370,RC,,,,,facility,both,,,,1257,942.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mac/Iv Sedation,3700000002,CDM,370,RC,,,,,facility,both,,,,362,271.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc General Anesthesia,3700000007,CDM,370,RC,,,,,facility,both,,,,1122,841.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
NITROGLYCERIN 0.4 MG/SPRAY SOLN 4.9 G BOTTLE,37074,CDM,250,RC,MHS1GM,HCPCS,45802021001,NDC,facility,both,1,GM,,37.23,27.92,,,,,,,,,,Gross Charge Type: Pharmacy
CHARCOAL ACTIVATED IN WATER LIQD,37077,CDM,250,RC,MHS1ML,HCPCS,574052174,NDC,facility,both,1,ML,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
CHARCOAL ACTIVATED IN WATER LIQD,37077,CDM,250,RC,MHS1ML,HCPCS,66689020204,NDC,facility,both,1,ML,,0.31,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/GM OINT,37178,CDM,250,RC,MHS1GM,HCPCS,904702367,NDC,facility,both,1,GM,,8.38,6.29,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/GM OINT,37178,CDM,250,RC,MHS1GM,HCPCS,536126328,NDC,facility,both,1,GM,,22.7,17.02,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/GM OINT,37178,CDM,250,RC,MHS1GM,HCPCS,57896014514,NDC,facility,both,1,GM,,21.79,16.35,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/GM OINT,37178,CDM,250,RC,FAMRXNC,HCPCS,57896014514,NDC,facility,both,1,GM,,22.4,16.8,,,,,,,,,,Gross Charge Type: Pharmacy
SALICYLIC ACID 17 % LIQD 9 ML BOTTLE,37216,CDM,250,RC,75137059110,NDC,,,facility,both,9,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE (500 MG ELEMENTAL CALCIUM) 1250 (500 CA) MG TABS,3730,CDM,250,RC,43292055565,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
COLESTIPOL 1 G TABS,37321,CDM,250,RC,9045003,NDC,,,facility,both,1,UN,,12.15,9.11,,,,,,,,,,Gross Charge Type: Pharmacy
COLESTIPOL 1 G TABS,37321,CDM,250,RC,59762045001,NDC,,,facility,both,0.5,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
COLESTIPOL 1 G TABS,37321,CDM,250,RC,59762045001,NDC,,,facility,both,2,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
COLESTIPOL 1 G TABS,37321,CDM,250,RC,59762045001,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE 100 MG/ML SOLN,3739,CDM,250,RC,MHS1ML,HCPCS,409492834,NDC,facility,both,1,ML,,4.82,3.61,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE 100 MG/ML SOLN,3739,CDM,250,RC,MHS1ML,HCPCS,409163110,NDC,facility,both,1,ML,,2.28,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE 100 MG/ML SOLN,3739,CDM,250,RC,MHS1ML,HCPCS,76329330401,NDC,facility,both,1,ML,,5.02,3.76,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE 100 MG/ML SOLN 10 ML SYRINGE,3739,CDM,250,RC,MHS1ML,HCPCS,409492834,NDC,facility,both,1,ML,,5.38,4.03,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE 100 MG/ML SOLN 10 ML SYRINGE,3739,CDM,250,RC,MHS1ML,HCPCS,409163110,NDC,facility,both,1,ML,,4.33,3.25,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE 100 MG/ML SOLN 10 ML VIAL,3739,CDM,250,RC,MHS1ML,HCPCS,517671010,NDC,facility,both,1,ML,,4.54,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN 500 MG TBCR,37476,CDM,250,RC,59651001890,NDC,,,facility,both,1,UN,,8.25,6.19,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN 500 MG TBCR,37476,CDM,250,RC,59651001890,NDC,,,facility,both,3,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN 500 MG TBCR,37476,CDM,250,RC,47335053981,NDC,,,facility,both,4,UN,,2.79,2.09,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN 500 MG TBCR,37476,CDM,250,RC,59651001890,NDC,,,facility,both,4,UN,,2.68,2.01,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN 500 MG TBCR,37476,CDM,250,RC,59651001890,NDC,,,facility,both,2,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,10,ML,,65.45,49.09,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,20,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,10,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,15,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,10,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,30,ML,,33.5,25.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,20,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,19.35,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.1,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.8,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,2.9,ML,,65.49,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.4,ML,,65.46,49.1,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,17.2,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.1,ML,,65.48,49.11,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,21.51,ML,,33.5,25.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,25.81,ML,,33.5,25.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.5,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,10,ML,,65.45,49.09,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,15.05,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,21.51,ML,,33.48,25.11,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,5,ML,,65.45,49.09,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.95,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,8.2,ML,,65.45,49.09,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,9.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,10.75,ML,,41.52,31.14,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.6,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,2.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.5,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.8,ML,,65.49,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.7,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.7,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,34.41,ML,,29.31,21.98,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,2.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.5,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,10,ML,,63.12,47.34,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.5,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,17.2,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,10.75,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.6,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.5,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,21.5,ML,,33.5,25.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.4,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,9.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.8,ML,,65.47,49.1,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.5,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,2.5,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,13.1,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.5,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.2,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,9.1,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.2,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.2,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,15.054,ML,,17.6,13.2,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,32.3,ML,,29.31,21.98,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,13.3,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,20,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.1,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,7.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,32.26,ML,,29.31,21.98,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.9,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,20,ML,,41.52,31.14,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,5,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,10.9,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,19.35,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.2,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.1,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,9.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.1,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,10,ML,,64.81,48.61,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.6,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,7.9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,15.05,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,24,ML,,33.5,25.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,6,ML,,65.45,49.09,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,2.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,30,ML,,33.5,25.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,7.3,ML,,65.46,49.1,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,7.8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.2,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,215.05,ML,,17.94,13.45,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,7.8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.45,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,12,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,15.9,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,10.5,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.9,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,10.11,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,9.3,ML,,65.45,49.09,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,10.75,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,9.68,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,9.5,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,5,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,14,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,20,ML,,41.42,31.06,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,7.2,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,10.8,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.04,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,1.8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.1,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,12,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,10.7,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.2,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.9,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.9,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,6.2,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.4,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,10.4,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,9.9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,10.1,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,2.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.8,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.5,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,2.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.8,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,30,ML,,33.5,25.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,7.53,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.1,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,12.3,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,25.81,ML,,33.48,25.11,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,5.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,7.9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,15.054,ML,,17.6,13.2,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.6,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036019,NDC,facility,both,30,ML,,33.48,25.11,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.4,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,9,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.3,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.95,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.6,ML,,65.49,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.7,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.1,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,25.81,ML,,33.5,25.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,21.51,ML,,33.5,25.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.8,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,8.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,11.6,ML,,41.55,31.16,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,both,3.2,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 10 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036019,NDC,facility,both,4.4,ML,,65.5,49.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 100 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,both,195.054,ML,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 100 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,both,20,ML,,31.45,23.59,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 100 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036005,NDC,facility,both,200,ML,,9.52,7.14,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 100 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036005,NDC,facility,both,200,ML,,9.52,7.14,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 100 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036005,NDC,facility,both,100,ML,,12.16,9.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 100 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036005,NDC,facility,both,205.054,ML,,9.23,6.92,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036059,NDC,facility,both,100,ML,,7.13,5.35,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036059,NDC,facility,both,195.054,ML,,9.52,7.14,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036059,NDC,facility,both,15.054,ML,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036059,NDC,facility,both,10,ML,,10.98,8.24,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036059,NDC,facility,both,15,ML,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036059,NDC,facility,both,20,ML,,17.08,12.81,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036059,NDC,facility,both,20,ML,,17.08,12.81,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036059,NDC,facility,both,200,ML,,9.52,7.14,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036059,NDC,facility,both,30,ML,,17.08,12.81,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036059,NDC,facility,both,15.054,ML,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036059,NDC,facility,both,10,ML,,11.53,8.65,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0610,HCPCS,63323036059,NDC,facility,both,100,ML,,12.16,9.12,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,250,RC,J0612,HCPCS,63323036059,NDC,facility,both,215.054,ML,,8.97,6.72,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036059,NDC,facility,both,20,ML,,17.08,12.81,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036059,NDC,facility,both,200,ML,,9.52,7.14,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 100 MG/ML SOLN 50 ML VIAL,3751,CDM,636,RC,J0612,HCPCS,63323036059,NDC,facility,both,5,ML,,17.08,12.81,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,904700761,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,68084031801,NDC,,,facility,both,2,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,904700761,NDC,,,facility,both,5,UN,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,68084031801,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,68382000601,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,68084031801,NDC,,,facility,both,4,UN,,2.31,1.73,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,904700761,NDC,,,facility,both,6,UN,,1.64,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,68382000601,NDC,,,facility,both,3,UN,,3,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,904700761,NDC,,,facility,both,9,UN,,1.22,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,68382000601,NDC,,,facility,both,4,UN,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,904700761,NDC,,,facility,both,2,UN,,3.96,2.97,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,904700761,NDC,,,facility,both,1,UN,,7.04,5.28,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,16714070001,NDC,,,facility,both,3,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,904700761,NDC,,,facility,both,3,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,904700761,NDC,,,facility,both,4,UN,,2.28,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 25 MG TABS,37578,CDM,250,RC,68382000601,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,2,UN,,3.66,2.75,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,3.5,UN,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,4,UN,,2.26,1.7,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,3,UN,,2.9,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,2.5,UN,,2.83,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,0.75,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,1.75,UN,,0.9,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,1,UN,,5.54,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,1.5,UN,,3.71,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG TABS,37579,CDM,250,RC,68084031901,NDC,,,facility,both,5,UN,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 200 MG TABS,37581,CDM,250,RC,16714019701,NDC,,,facility,both,2,UN,,1.96,1.47,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 200 MG TABS,37581,CDM,250,RC,16714019701,NDC,,,facility,both,0.125,UN,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 200 MG TABS,37581,CDM,250,RC,16714019701,NDC,,,facility,both,0.5,UN,,5.96,4.47,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 200 MG TABS,37581,CDM,250,RC,16714019701,NDC,,,facility,both,0.75,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 200 MG TABS,37581,CDM,250,RC,16714019701,NDC,,,facility,both,1,UN,,5.8,4.35,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 200 MG TABS,37581,CDM,250,RC,29300011416,NDC,,,facility,both,1,UN,,5.26,3.95,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 200 MG TABS,37581,CDM,250,RC,16714019701,NDC,,,facility,both,1.5,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
BETAXOLOL 0.5 % SOLN 5 ML BOTTLE,37604,CDM,250,RC,MHS1ML,HCPCS,61314024501,NDC,facility,both,1,ML,,21.35,16.01,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 1 % GEL,37606,CDM,250,RC,16714016102,NDC,,,facility,both,60,GR,,174.1,130.58,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 1 % GEL 30 G TUBE,37606,CDM,250,RC,168020230,NDC,,,facility,both,30,GR,,165.85,124.39,,,,,,,,,,Gross Charge Type: Pharmacy
KETOCONAZOLE 2 % CREA 30 G TUBE,37622,CDM,250,RC,MHS1GM,HCPCS,168009930,NDC,facility,both,1,GM,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM 7.5 MG TABS,37672,CDM,250,RC,50268052515,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM 7.5 MG TABS,37672,CDM,250,RC,50268052515,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
FEXOFENADINE 60 MG TABS,37697,CDM,250,RC,41167413102,NDC,,,facility,both,1,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
FEXOFENADINE 60 MG TABS,37697,CDM,250,RC,55111078301,NDC,,,facility,both,3,UN,,2.87,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
FEXOFENADINE 60 MG TABS,37697,CDM,250,RC,55111078301,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
FEXOFENADINE 180 MG TABS,37714,CDM,250,RC,55111078401,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
FEXOFENADINE 180 MG TABS,37714,CDM,250,RC,55111078401,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG TBEC,37732,CDM,250,RC,378668977,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG TBEC,37732,CDM,250,RC,60687073609,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG TBEC,37732,CDM,250,RC,904687045,NDC,,,facility,both,2,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG TBEC,37732,CDM,250,RC,904687045,NDC,,,facility,both,1,UN,,6.99,5.24,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG TBEC,37732,CDM,250,RC,50268063915,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG TBEC,37732,CDM,250,RC,51079005120,NDC,,,facility,both,1,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 250 MG TABS,37758,CDM,250,RC,904712361,NDC,,,facility,both,2,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 250 MG TABS,37758,CDM,250,RC,904712361,NDC,,,facility,both,4,UN,,2.31,1.73,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 250 MG TABS,37758,CDM,250,RC,904712361,NDC,,,facility,both,1.5,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 250 MG TABS,37758,CDM,250,RC,904712361,NDC,,,facility,both,3,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 250 MG TABS,37758,CDM,250,RC,904712361,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 250 MG TABS,37758,CDM,250,RC,904712361,NDC,,,facility,both,4.5,UN,,1.89,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,904712461,NDC,,,facility,both,2.5,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,904712461,NDC,,,facility,both,2,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,51079082120,NDC,,,facility,both,1.5,UN,,4.78,3.58,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,51079082120,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,51079082120,NDC,,,facility,both,0.5,UN,,7.85,5.89,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,51079082120,NDC,,,facility,both,2,UN,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,60687065701,NDC,,,facility,both,2,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,904712461,NDC,,,facility,both,4,UN,,2.22,1.67,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,904712461,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,51079082120,NDC,,,facility,both,3,UN,,3.82,2.86,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,60687065701,NDC,,,facility,both,3,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,16714003501,NDC,,,facility,both,1,UN,,6.56,4.92,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,60687065701,NDC,,,facility,both,1.5,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,904712461,NDC,,,facility,both,3.5,UN,,2.18,1.63,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,16714003501,NDC,,,facility,both,1.5,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,904712461,NDC,,,facility,both,3,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,16714003501,NDC,,,facility,both,2,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,60687065701,NDC,,,facility,both,4,UN,,2.5,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,16714003501,NDC,,,facility,both,3,UN,,2.8,2.1,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,60687065701,NDC,,,facility,both,1,UN,,7.37,5.53,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,60687065701,NDC,,,facility,both,0.5,UN,,3.85,2.89,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,904712461,NDC,,,facility,both,0.5,UN,,6.38,4.78,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG TABS,37759,CDM,250,RC,904712461,NDC,,,facility,both,1,UN,,6.42,4.82,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG CP12,37907,CDM,250,RC,51079092420,NDC,,,facility,both,2,UN,,10,7.5,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG CP12,37907,CDM,250,RC,16714055301,NDC,,,facility,both,4,UN,,6,4.5,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG CP12,37907,CDM,250,RC,51079092420,NDC,,,facility,both,1,UN,,14.3,10.72,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG CP12,37907,CDM,250,RC,16714055301,NDC,,,facility,both,2,UN,,8.25,6.19,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG CP12,37907,CDM,250,RC,51079092420,NDC,,,facility,both,4,UN,,7.66,5.75,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG CP12,37907,CDM,250,RC,68462085001,NDC,,,facility,both,1,UN,,13,9.75,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG CP12,37907,CDM,250,RC,16714055301,NDC,,,facility,both,1,UN,,11.52,8.64,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG CP12,37908,CDM,250,RC,68462085101,NDC,,,facility,both,1,UN,,13.65,10.24,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG CP12,37908,CDM,250,RC,51079092520,NDC,,,facility,both,1,UN,,15.55,11.66,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG CP12,37908,CDM,250,RC,378609001,NDC,,,facility,both,2,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG CP12,37908,CDM,250,RC,378609001,NDC,,,facility,both,1,UN,,13.75,10.31,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN ENTERIC COATED 81 MG TBEC,37928,CDM,250,RC,63739021202,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 4 MG CHEW,37959,CDM,250,RC,57237021230,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
CEVIMELINE 30 MG CAPS,37984,CDM,250,RC,16571065710,NDC,,,facility,both,1,UN,,11.2,8.4,,,,,,,,,,Gross Charge Type: Pharmacy
CEVIMELINE 30 MG CAPS,37984,CDM,250,RC,54033425,NDC,,,facility,both,1,UN,,13.1,9.82,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG CHEW,38028,CDM,250,RC,573017920,NDC,,,facility,both,1.5,UN,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG CHEW,38028,CDM,250,RC,573017920,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG CHEW,38028,CDM,250,RC,573017920,NDC,,,facility,both,2.5,UN,,2.82,2.11,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG CHEW,38028,CDM,250,RC,70677007201,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG CHEW,38028,CDM,250,RC,573017920,NDC,,,facility,both,2,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG CHEW,38028,CDM,250,RC,573017920,NDC,,,facility,both,3,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME 2 G SOLR,38036,CDM,250,RC,25021012850,NDC,,,facility,both,500,ME,,72.85,54.64,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME 2 G SOLR,38036,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,both,500,ME,,18.21,13.66,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME 2 G SOLR 1 EACH VIAL,38036,CDM,636,RC,J0713,HCPCS,25021012850,NDC,facility,both,500,ME,,17.83,13.37,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME 2 G SOLR 1 EACH VIAL,38036,CDM,636,RC,J0713,HCPCS,44567023610,NDC,facility,both,500,ME,,16.2,12.15,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME 2 G SOLR 1 EACH VIAL,38036,CDM,250,RC,25021012850,NDC,,,facility,both,500,ME,,71.08,53.31,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 G SOLR,38061,CDM,636,RC,J0692,HCPCS,60505614700,NDC,facility,both,500,ME,,14.52,10.89,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 G SOLR 1 EACH VIAL,38061,CDM,636,RC,J0692,HCPCS,60505614700,NDC,facility,both,500,ME,,14.53,10.9,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME SOLR,38061,CDM,636,RC,J0692,HCPCS,60505614700,NDC,facility,both,500,ME,,14.52,10.89,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME SOLR 1 EACH VIAL,38061,CDM,636,RC,J0692,HCPCS,60505614700,NDC,facility,both,500,ME,,14.53,10.9,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VACCINE 10 MCG/0.5ML SUSP,38081,CDM,636,RC,90744,HCPCS,58160082052,NDC,facility,both,0.5,ML,,79.2,59.4,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VACCINE 20 MCG/ML SUSP,38082,CDM,636,RC,90746,HCPCS,58160082152,NDC,facility,both,1,ML,,102.2,76.65,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL LIGHT OIL,38189,CDM,250,RC,MHS1ML,HCPCS,63323025410,NDC,facility,both,1,ML,,2.65,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL LIGHT OIL 10 ML VIAL,38189,CDM,250,RC,MHS1ML,HCPCS,63323025410,NDC,facility,both,1,ML,,2.42,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/ML SOLN,38224,CDM,636,RC,J2270,HCPCS,641612725,NDC,facility,both,10,ME,,37.52,28.14,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE SULFATE 10 MG/ML SOLN 1 ML VIAL,38224,CDM,636,RC,J2270,HCPCS,641612725,NDC,facility,both,10,ME,,9.62,7.21,,,,,,,,,,Gross Charge Type: Pharmacy
VINORELBINE 10 MG/ML SOLN 1 ML VIAL,38266,CDM,636,RC,J9390,HCPCS,25021020401,NDC,facility,both,10,ME,,33.81,25.36,,,,,,,,,,Gross Charge Type: Pharmacy
VINORELBINE 10 MG/ML SOLN 5 ML VIAL,38266,CDM,636,RC,J9390,HCPCS,45963060756,NDC,facility,both,10,ME,,68.13,51.1,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML SUSR,38307,CDM,250,RC,MHS5ML,HCPCS,16714069601,NDC,facility,both,5,ML,,9.18,6.89,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 150 MG TABS,38354,CDM,250,RC,60687069301,NDC,,,facility,both,0.3333,UN,,0.9,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 150 MG TABS,38354,CDM,250,RC,16714019601,NDC,,,facility,both,1,UN,,3.82,2.86,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 150 MG TABS,38354,CDM,250,RC,16714019601,NDC,,,facility,both,1.6667,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 150 MG TABS,38354,CDM,250,RC,60687069301,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 150 MG TABS,38354,CDM,250,RC,16714019601,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 150 MG TABS,38354,CDM,250,RC,16714019601,NDC,,,facility,both,3,UN,,2.5,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 150 MG TABS,38354,CDM,250,RC,60687069301,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 150 MG TABS,38354,CDM,250,RC,16714019601,NDC,,,facility,both,2,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 400 MG TB24,38445,CDM,250,RC,29033000101,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 400 MG TB24,38445,CDM,250,RC,29033000101,NDC,,,facility,both,0.5,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML INJ 10 ML VIAL,38501,CDM,636,RC,Q2050,HCPCS,72603010301,NDC,facility,both,10,ME,,292.18,219.13,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML INJ 10 ML VIAL,38501,CDM,636,RC,Q2050,HCPCS,43598028335,NDC,facility,both,10,ME,,349.14,261.85,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML INJ 10 ML VIAL,38501,CDM,636,RC,Q2050,HCPCS,16714074201,NDC,facility,both,10,ME,,312.56,234.42,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML INJ 25 ML VIAL,38501,CDM,636,RC,Q2050,HCPCS,43598054125,NDC,facility,both,10,ME,,325.95,244.46,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML INJ 25 ML VIAL,38501,CDM,636,RC,Q2050,HCPCS,70710153101,NDC,facility,both,10,ME,,692.76,519.57,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML INJ 25 ML VIAL,38501,CDM,636,RC,Q2050,HCPCS,47335005040,NDC,facility,both,10,ME,,986.91,740.18,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML INJ 25 ML VIAL,38501,CDM,636,RC,Q2050,HCPCS,72603020001,NDC,facility,both,10,ME,,318.23,238.67,,,,,,,,,,Gross Charge Type: Pharmacy
CAPSAICIN 0.025 % CREA 60 G TUBE,3867,CDM,250,RC,536252525,NDC,,,facility,both,60,GR,,49.25,36.94,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG CHEW,3872,CDM,250,RC,60687047901,NDC,,,facility,both,2,UN,,4.9,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG CHEW,3872,CDM,250,RC,904385461,NDC,,,facility,both,3,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG CHEW,3872,CDM,250,RC,904385461,NDC,,,facility,both,1,UN,,7.53,5.65,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG CHEW,3872,CDM,250,RC,60687047901,NDC,,,facility,both,3,UN,,3.62,2.71,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG CHEW,3872,CDM,250,RC,904385461,NDC,,,facility,both,4,UN,,2.9,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG CHEW,3872,CDM,250,RC,60687047901,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5ML SUSP,3873,CDM,250,RC,MHS5ML,HCPCS,60432012916,NDC,facility,both,5,ML,,2.55,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TABS,3874,CDM,250,RC,904617261,NDC,,,facility,both,4,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TABS,3874,CDM,250,RC,904617261,NDC,,,facility,both,1.5,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TABS,3874,CDM,250,RC,904617261,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TABS,3874,CDM,250,RC,51079038520,NDC,,,facility,both,2,UN,,5.18,3.88,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TABS,3874,CDM,250,RC,904617261,NDC,,,facility,both,3,UN,,3.93,2.95,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TABS,3874,CDM,250,RC,51079038520,NDC,,,facility,both,3,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TABS,3874,CDM,250,RC,904617261,NDC,,,facility,both,0.5,UN,,8.05,6.04,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TABS,3874,CDM,250,RC,51079038520,NDC,,,facility,both,1.5,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TABS,3874,CDM,250,RC,904617261,NDC,,,facility,both,2,UN,,5.22,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE 6.5 % SOLN,3876,CDM,250,RC,MHS5ML,HCPCS,78112073621,NDC,facility,both,5,ML,,17.45,13.09,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE 6.5 % SOLN 15 ML BOTTLE,3876,CDM,250,RC,MHS5ML,HCPCS,78112073621,NDC,facility,both,5,ML,,20.52,15.39,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.075 MG/24HR PTTW,38840,CDM,250,RC,65162099504,NDC,,,facility,both,1,UN,,33.9,25.42,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.025 MG/24HR PTWK,38861,CDM,250,RC,781711958,NDC,,,facility,both,1,UN,,52.3,39.22,,,,,,,,,,Gross Charge Type: Pharmacy
DINOPROSTONE 10 MG INST,38869,CDM,250,RC,55566280001,NDC,,,facility,both,1,UN,,704.85,528.64,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.1 MG/HR PT24,38875,CDM,250,RC,378910293,NDC,,,facility,both,1,UN,,21.3,15.98,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.2 MG/HR PT24,38876,CDM,250,RC,378910493,NDC,,,facility,both,1,UN,,21.05,15.79,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % SOLN 10 ML BOTTLE,38884,CDM,250,RC,MHS1ML,HCPCS,61314001910,NDC,facility,both,1,ML,,6.93,5.2,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % SOLN 10 ML BOTTLE,38884,CDM,250,RC,MHS1ML,HCPCS,42571014126,NDC,facility,both,1,ML,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % SOLN 10 ML BOTTLE,38884,CDM,250,RC,MHS1ML,HCPCS,70377008111,NDC,facility,both,1,ML,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % SOLN 10 ML BOTTLE,38884,CDM,250,RC,MHS1ML,HCPCS,24208048510,NDC,facility,both,1,ML,,8.04,6.03,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 2.5 MG TB24,38930,CDM,250,RC,13668013201,NDC,,,facility,both,2,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 2.5 MG TB24,38930,CDM,250,RC,13668013201,NDC,,,facility,both,3,UN,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 2.5 MG TB24,38930,CDM,250,RC,13668013201,NDC,,,facility,both,1,UN,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 5 MG TB24,38950,CDM,250,RC,68462023401,NDC,,,facility,both,2,UN,,4.02,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 5 MG TB24,38950,CDM,250,RC,603358221,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 5 MG TB24,38950,CDM,250,RC,68462023401,NDC,,,facility,both,1,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Antigen Typing Donor,3908690201,CDM,390,RC,86902,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rh Phenotype,3908690601,CDM,390,RC,86906,HCPCS,,,facility,both,,,,212,159,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Compatibility Test Ahg,3908692201,CDM,390,RC,86922,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cold Agglutinin Screen,3908694001,CDM,390,RC,86940,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Red Cell Treatment,3908697001,CDM,390,RC,86970,HCPCS,,,facility,both,,,,113,84.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Red Cell Treatment,3908697001,CDM,390,RC,86970,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Bonner & Boundary (Lab) 10815341 Unit Charge
Hc Saline Replacement Setup,3908697601,CDM,390,RC,86976,HCPCS,,,facility,both,,,,254,190.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Saline Replacement Setup,3908697601,CDM,390,RC,86976,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Splitting Of Blood Or Blood Products,3908698501,CDM,390,RC,86985,HCPCS,,,facility,both,,,,194,145.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Whole Blood,390P901001,CDM,390,RC,P9010,HCPCS,,,facility,both,,,,898,673.5,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Whole Blood,390P901001,CDM,390,RC,P9010,HCPCS,,,facility,both,,,,898,673.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Neonate Prbcs Tranfuse (Split Unit),390P901101,CDM,390,RC,P9011,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cryo, Pooled, Each Unit",390P901201,CDM,390,RC,P9012,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rbc; Leukoreduced,390P901601,CDM,390,RC,P9016,HCPCS,,,facility,both,,,,719,539.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Red Blood Cells, Autologous",390P902101,CDM,390,RC,P9021,HCPCS,,,facility,both,,,,369,276.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Red Blood Cells Washed,390P902201,CDM,390,RC,P9022,HCPCS,,,facility,both,,,,481,360.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Platelets, Pheresis, Leukocytes Reduced, Each Unit",390P903501,CDM,390,RC,P9035,HCPCS,,,facility,both,,,,2165,1623.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Plts;Pheresis,Leukored,Irrad",390P903701,CDM,390,RC,P9037,HCPCS,,,facility,both,,,,2052,1539,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rbc; Leukoreduced, Irradiated",390P904001,CDM,390,RC,P9040,HCPCS,,,facility,both,,,,774,580.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Plasma, Cryoprecipitate Reduced, Each Unit",390P904401,CDM,390,RC,P9044,HCPCS,,,facility,both,,,,130,97.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Plts;Pheresis,Lkrdc,Hla Match",390P905201,CDM,390,RC,P9052,HCPCS,,,facility,both,,,,1984,1488,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Rbc; Leukored,Irrad,Cmv Neg",390P905801,CDM,390,RC,P9058,HCPCS,,,facility,both,,,,960,720,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Plasma, Fresh Frozen",390P905901,CDM,390,RC,P9059,HCPCS,,,facility,both,,,,290,217.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Platelets, Pheresis, Pathogen-Reduced, Each Unit",390P907301,CDM,390,RC,P9073,HCPCS,,,facility,both,,,,2263,1697.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Platelets, Pheresis, Pathogen-Reduced, Each Unit",390P907301,CDM,390,RC,P9073,HCPCS,,,facility,both,,,,1968,1476,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
TERAZOSIN 1 MG CAPS,39139,CDM,250,RC,50268076411,NDC,,,facility,both,1,UN,,9.45,7.09,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 1 MG CAPS,39139,CDM,250,RC,59746038306,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 1 MG CAPS,39139,CDM,250,RC,51079093620,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 2 MG CAPS,39140,CDM,250,RC,59746038406,NDC,,,facility,both,2,UN,,3.78,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 2 MG CAPS,39140,CDM,250,RC,59746038406,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 5 MG CAPS,39142,CDM,250,RC,50268076611,NDC,,,facility,both,4,UN,,3.66,2.75,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 5 MG CAPS,39142,CDM,250,RC,59746038506,NDC,,,facility,both,1,UN,,6.69,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 5 MG CAPS,39142,CDM,250,RC,50268076611,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 5 MG CAPS,39142,CDM,250,RC,59746038506,NDC,,,facility,both,4,UN,,2.18,1.63,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 5 MG CAPS,39142,CDM,250,RC,50268076611,NDC,,,facility,both,2,UN,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 5 MG CAPS,39142,CDM,250,RC,51079093820,NDC,,,facility,both,2,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 5 MG CAPS,39142,CDM,250,RC,50268076615,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 5 MG CAPS,39142,CDM,250,RC,59746038506,NDC,,,facility,both,2,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN 5 MG CAPS,39142,CDM,250,RC,51079093820,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE-PSEUDOEPHEDRINE 5-120 MG TB12,39228,CDM,250,RC,70677003601,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
FEXOFENADINE-PSEUDOEPHEDRINE 60-120 MG TB12,39234,CDM,250,RC,41167431006,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG TB12,39276,CDM,250,RC,63824005634,NDC,,,facility,both,2,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG TB12,39276,CDM,250,RC,536116137,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG TB12,39276,CDM,250,RC,63824005634,NDC,,,facility,both,1,UN,,8.3,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG TBCR,39312,CDM,250,RC,68462029301,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG TBCR,39312,CDM,250,RC,68462029301,NDC,,,facility,both,1,UN,,8.05,6.04,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 75 MG CPCR,39315,CDM,250,RC,31722056560,NDC,,,facility,both,1,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL 50 MG TABS,39326,CDM,250,RC,60687079501,NDC,,,facility,both,1,UN,,6.67,5.01,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL 50 MG TABS,39326,CDM,250,RC,57664037708,NDC,,,facility,both,2,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL 50 MG TABS,39326,CDM,250,RC,60687079501,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL 50 MG TABS,39326,CDM,250,RC,60687079501,NDC,,,facility,both,2,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL 50 MG TABS,39326,CDM,250,RC,57664037708,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL 50 MG TABS,39326,CDM,250,RC,57664037708,NDC,,,facility,both,0.5,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
CARISOPRODOL 350 MG TABS,3943,CDM,250,RC,50228010901,NDC,,,facility,both,1,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
CARISOPRODOL 350 MG TABS,3943,CDM,250,RC,69584011110,NDC,,,facility,both,1,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
CARISOPRODOL 350 MG TABS,3943,CDM,250,RC,50228010901,NDC,,,facility,both,1.5,UN,,2.78,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
CARISOPRODOL 350 MG TABS,3943,CDM,250,RC,69584011110,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 850 MG TABS,39510,CDM,250,RC,60687014301,NDC,,,facility,both,1.5,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 850 MG TABS,39510,CDM,250,RC,60687014301,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG TABS,39512,CDM,250,RC,51991073520,NDC,,,facility,both,1,UN,,15,11.25,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG TABS,39512,CDM,250,RC,51991073520,NDC,,,facility,both,2,UN,,10.65,7.99,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG TABS,39512,CDM,250,RC,69452035011,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN 5 MG TBDP,39572,CDM,250,RC,69452015674,NDC,,,facility,both,2,UN,,5.88,4.41,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN 5 MG TBDP,39572,CDM,250,RC,69452015674,NDC,,,facility,both,1,UN,,9.75,7.31,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN 10 MG TBDP,39575,CDM,250,RC,65862062690,NDC,,,facility,both,1,UN,,11.75,8.81,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN 10 MG TBDP,39575,CDM,250,RC,65862062690,NDC,,,facility,both,2,UN,,7.78,5.83,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG TB12,39579,CDM,250,RC,51672412301,NDC,,,facility,both,2,UN,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG TB12,39579,CDM,250,RC,59746078901,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG TB12,39579,CDM,250,RC,51672412301,NDC,,,facility,both,1,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG TB12,39579,CDM,250,RC,51672412301,NDC,,,facility,both,3,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TB12,39580,CDM,250,RC,51672412401,NDC,,,facility,both,1,UN,,10.5,7.88,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TB12,39580,CDM,250,RC,60687058321,NDC,,,facility,both,4,UN,,7.95,5.96,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TB12,39580,CDM,250,RC,60687058321,NDC,,,facility,both,1,UN,,14.65,10.99,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TB12,39580,CDM,250,RC,60687058321,NDC,,,facility,both,0.5,UN,,11.3,8.48,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TB12,39580,CDM,250,RC,60687058321,NDC,,,facility,both,2,UN,,10.3,7.72,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TB12,39580,CDM,250,RC,51672412401,NDC,,,facility,both,2,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TB12,39580,CDM,250,RC,60687058321,NDC,,,facility,both,3,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TB12,39580,CDM,250,RC,51672412401,NDC,,,facility,both,3,UN,,5.23,3.92,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG TB12,39580,CDM,250,RC,60687058321,NDC,,,facility,both,1.5,UN,,8.82,6.62,,,,,,,,,,Gross Charge Type: Pharmacy
TERBINAFINE 250 MG TABS,396,CDM,250,RC,16714079501,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
TERBINAFINE 250 MG TABS,396,CDM,250,RC,16714079501,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
TERBINAFINE 250 MG TABS,396,CDM,250,RC,16714079501,NDC,,,facility,both,0.25,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 15 MG CPSP,39604,CDM,250,RC,68382000414,NDC,,,facility,both,3,UN,,4.8,3.6,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-DIPYRIDAMOLE 25-200 MG CP12,39617,CDM,250,RC,16714096401,NDC,,,facility,both,1,UN,,9.7,7.28,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG STRP,39650,CDM,250,RC,17238090011,NDC,,,facility,both,1,UN,,24.25,18.19,,,,,,,,,,Gross Charge Type: Pharmacy
COAL TAR EXTRACT 0.5 % SHAM 240 ML BOTTLE,39693,CDM,250,RC,96073708,NDC,,,facility,both,240,ML,,51,38.25,,,,,,,,,,Gross Charge Type: Pharmacy
COAL TAR EXTRACT 0.5 % SHAM 251 ML BOTTLE,39693,CDM,250,RC,904525944,NDC,,,facility,both,251,ML,,41.05,30.79,,,,,,,,,,Gross Charge Type: Pharmacy
TROLAMINE SALICYLATE 10 % CREA 141 G TUBE,39734,CDM,250,RC,41167005724,NDC,,,facility,both,141,GR,,18.55,13.91,,,,,,,,,,Gross Charge Type: Pharmacy
TROLAMINE SALICYLATE 10 % CREA 85 G TUBE,39734,CDM,250,RC,49348088384,NDC,,,facility,both,85,GR,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE-BENAZEPRIL 2.5-10 MG CAPS,39797,CDM,250,RC,65862058201,NDC,,,facility,both,1,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE-BENAZEPRIL 2.5-10 MG CAPS,39797,CDM,250,RC,65862058201,NDC,,,facility,both,2,UN,,4.28,3.21,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE BENAZEPRIL 5-10 MG CAPS,39798,CDM,250,RC,55111033901,NDC,,,facility,both,2,UN,,3.95,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE BENAZEPRIL 5-10 MG CAPS,39798,CDM,250,RC,55111033901,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE-BENAZEPRIL 5-20 MG CAPS,39799,CDM,250,RC,68180045901,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE-BENAZEPRIL 5-20 MG CAPS,39799,CDM,250,RC,68180045901,NDC,,,facility,both,2,UN,,3.98,2.98,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE-BENAZEPRIL 5-20 MG CAPS,39799,CDM,250,RC,55111034001,NDC,,,facility,both,2,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE-BENAZEPRIL 5-20 MG CAPS,39799,CDM,250,RC,55111034001,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,68084034601,NDC,,,facility,both,4,UN,,2.94,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,68084034601,NDC,,,facility,both,1.5,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,31722070090,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,68084034601,NDC,,,facility,both,0.5,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,68084034601,NDC,,,facility,both,1,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,31722070090,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,31722070090,NDC,,,facility,both,4,UN,,2,1.5,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,68084034601,NDC,,,facility,both,3,UN,,3.58,2.69,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,68084034601,NDC,,,facility,both,0.49,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 25 MG TABS,39800,CDM,250,RC,68084034601,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,904704861,NDC,,,facility,both,0.5,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,78206012201,NDC,,,facility,both,2,UN,,11.2,8.4,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,904704861,NDC,,,facility,both,1,UN,,7.73,5.8,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,78206012201,NDC,,,facility,both,1,UN,,15.65,11.74,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,68084034701,NDC,,,facility,both,0.5,UN,,7.95,5.96,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,68084034701,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,68084034701,NDC,,,facility,both,3,UN,,3.85,2.89,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,68084034701,NDC,,,facility,both,2,UN,,5.15,3.86,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,904704861,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,78206012201,NDC,,,facility,both,0.5,UN,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 50 MG TABS,39801,CDM,250,RC,68084034701,NDC,,,facility,both,1.5,UN,,4.82,3.62,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 30 MG CPDR,39811,CDM,250,RC,55111039990,NDC,,,facility,both,1,UN,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE 20 MG CPDR,39817,CDM,250,RC,57237016130,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG OR TBDP,39840,CDM,65862039010,NDC,,,,,facility,both,2,EA,,9.11,6.83,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG OR TBDP,39840,CDM,57237007710,NDC,,,,,facility,both,1,EA,,25.35,19.01,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG OR TBDP,39840,CDM,57237007710,NDC,,,,,facility,both,2,EA,,19.46,14.59,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG OR TBDP,39840,CDM,16714020010,NDC,,,,,facility,both,2,EA,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG OR TBDP,39840,CDM,16714020010,NDC,,,,,facility,both,1,EA,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG OR TBDP,39840,CDM,65862039010,NDC,,,,,facility,both,1,EA,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG OR TBDP,39840,CDM,65862039010,NDC,,,,,facility,both,1,EA,,15.11,11.33,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG OR TBDP,39840,CDM,65862039010,NDC,,,,,facility,both,2,EA,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,Q0162,HCPCS,65862039010,NDC,facility,both,0.5,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,57237007710,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,57237007730,NDC,,,facility,both,1,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,Q0162,HCPCS,57237007710,NDC,facility,both,1,UN,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,16714020010,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,57237007730,NDC,,,facility,both,2,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,65862039010,NDC,,,facility,both,4,UN,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,J8597,HCPCS,65862039010,NDC,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,S0119,HCPCS,65862039010,NDC,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,S0119,HCPCS,65862039010,NDC,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,J8597,HCPCS,65862039010,NDC,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,Q0162,HCPCS,65862039010,NDC,facility,both,2,UN,,1.06,0.8,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,57237007710,NDC,,,facility,both,0.5,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,65862039010,NDC,,,facility,both,1,UN,,7.3,5.47,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,57237007710,NDC,,,facility,both,1,UN,,7.57,5.68,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,65862039010,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,Q0162,HCPCS,57237007710,NDC,facility,both,0.5,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,Q0162,HCPCS,57237007710,NDC,facility,both,2,UN,,1.09,0.82,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,65862039010,NDC,,,facility,both,0.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,39840,CDM,250,RC,Q0162,HCPCS,65862039010,NDC,facility,both,1,UN,,1.82,1.37,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG TBDP,39841,CDM,250,RC,65862039110,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG TBDP,39841,CDM,250,RC,57237007810,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE IN D5W 1600 MCG/ML SOLN,39864,CDM,636,RC,J1265,HCPCS,338100702,NDC,facility,both,40,ME,,7.53,5.65,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE IN D5W 1600 MCG/ML SOLN,39864,CDM,636,RC,J1265,HCPCS,409780922,NDC,facility,both,40,ME,,6.78,5.08,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE-DEXTROSE 1600 MCG/ML SOLN,39864,CDM,636,RC,J1265,HCPCS,338100702,NDC,facility,both,40,ME,,7.53,5.65,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE-DEXTROSE 1600 MCG/ML SOLN,39864,CDM,636,RC,J1265,HCPCS,409780922,NDC,facility,both,40,ME,,6.78,5.08,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE 25 MG TABS,39866,CDM,250,RC,70677006801,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE 25 MG TABS,39866,CDM,250,RC,70677006801,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D5W 4 MG/ML SOLN,39913,CDM,250,RC,MHS1ML,HCPCS,338040903,NDC,facility,both,1,ME,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D5W 4 MG/ML SOLN,39913,CDM,250,RC,338040903,NDC,,,facility,both,1,ME,,69.15,51.86,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE (DECADRON)  0.1 MG/ML IN NS DILUTION 0.1 MG/ML,4000001,CDM,636,RC,J1100,HCPCS,63323050601,NDC,facility,both,1,ME,,44.77,33.58,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE (DECADRON) 1 MG/ML IN NS DILUTION 1 MG/ML,4000502,CDM,636,RC,J1100,HCPCS,641036725,NDC,facility,both,1,ME,,25.33,19,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE (SOLU-CORTEF) 1 MG/ML IN NS DILUTION 1 MG/ML,4000507,CDM,636,RC,J1720,HCPCS,9001103,NDC,facility,both,100,ME,,27.45,20.59,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE (SOLU-MEDROL) 10 MG/ML IN NS DILUTION 10 MG/ML,4000509,CDM,636,RC,J2920,HCPCS,9003933,NDC,facility,both,5,ME,,38.23,28.67,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 2 MG/ML IN NS DILUTION 2 MG/ML,4000512,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,both,40,ML,,26.03,19.52,,,,,,,,,,Gross Charge Type: Pharmacy
"CEFAZOLIN (ANCEF, KEFZOL) 100 MG/ML IN SW SOLUTION 100 MG/ML",4000521,CDM,636,RC,J0690,HCPCS,66288110001,NDC,facility,both,500,ME,,17.09,12.82,,,,,,,,,,Gross Charge Type: Pharmacy
"CEFAZOLIN (ANCEF, KEFZOL) 100 MG/ML IN SW SOLUTION 100 MG/ML",4000521,CDM,636,RC,J0690,HCPCS,66288130001,NDC,facility,both,500,ME,,36.14,27.1,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV (BOLUS) 10 MG/ML EMUL,4000604,CDM,636,RC,J2704,HCPCS,25021060820,NDC,facility,both,10,ME,,2.09,1.57,,,,,,,,,,Gross Charge Type: Pharmacy
SECONDARY NTG TUBING 1 EACH PACKAGE,4000628,CDM,250,RC,85412046360,NDC,,,facility,both,1,UN,,28,21,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9% NACL (EXCEL BAG) 1,000 ML FLEX CONT",4000647,CDM,250,RC,J7030,HCPCS,264780009,NDC,facility,both,10,ML,,48.1,36.08,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9% NACL (EXCEL BAG) 1,000 ML FLEX CONT",4000647,CDM,250,RC,J7030,HCPCS,264780000,NDC,facility,both,10,ML,,40.4,30.3,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL (EXCEL BAG) 100 ML FLEX CONT,4000647,CDM,250,RC,J7030,HCPCS,264180032,NDC,facility,both,10,ML,,43.13,32.35,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL (EXCEL BAG) 100 ML FLEX CONT,4000647,CDM,250,RC,MHS10ML,HCPCS,264180032,NDC,facility,both,10,ML,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL (EXCEL BAG) 250 ML FLEX CONT,4000647,CDM,250,RC,J7030,HCPCS,264780020,NDC,facility,both,10,ML,,45.06,33.8,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL (EXCEL BAG) 250 ML FLEX CONT,4000647,CDM,250,RC,MHS10ML,HCPCS,264780020,NDC,facility,both,10,ML,,1.69,1.27,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL (EXCEL BAG) 250 ML FLEX CONT,4000647,CDM,250,RC,J7030,HCPCS,338004902,NDC,facility,both,10,ML,,36.55,27.41,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL (EXCEL BAG) 500 ML FLEX CONT,4000647,CDM,250,RC,J7030,HCPCS,264780010,NDC,facility,both,10,ML,,49.51,37.13,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL (EXCEL BAG) 500 ML FLEX CONT,4000647,CDM,250,RC,MHS10ML,HCPCS,264780010,NDC,facility,both,10,ML,,0.89,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE 1600 MCG/ML 250 ML PLAS CONT,4000674,CDM,636,RC,J1265,HCPCS,338100702,NDC,facility,both,40,ME,,7.53,5.65,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 5 MG/ML,4000687,CDM,636,RC,J1836,HCPCS,409015224,NDC,facility,both,10,ME,,1.21,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML,4000689,CDM,636,RC,J2020,HCPCS,9780702,NDC,facility,both,200,ME,,18.33,13.75,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML,4000689,CDM,636,RC,J2020,HCPCS,57664068357,NDC,facility,both,200,ME,,34.73,26.05,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML,4000689,CDM,636,RC,J2020,HCPCS,66794021943,NDC,facility,both,200,ME,,24.22,18.16,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 2 MG/ML,4000689,CDM,636,RC,J2020,HCPCS,55150024251,NDC,facility,both,200,ME,,27.1,20.32,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 2 MG/ML IN D5W 2 MG/ML,4000690,CDM,636,RC,J0744,HCPCS,25021011482,NDC,facility,both,200,ME,,106.95,80.21,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 2 MG/ML IN D5W 2 MG/ML,4000690,CDM,636,RC,J0744,HCPCS,25021019287,NDC,facility,both,200,ME,,61.42,46.07,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 2 MG/ML IN D5W 2 MG/ML,4000690,CDM,636,RC,J0744,HCPCS,25021011487,NDC,facility,both,200,ME,,23.28,17.46,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE,4000729,CDM,636,RC,J2270,HCPCS,76045000511,NDC,facility,both,10,ME,,34.47,25.85,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE,4000729,CDM,636,RC,J2270,HCPCS,409189101,NDC,facility,both,10,ME,,35.55,26.66,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE,4000730,CDM,636,RC,J1170,HCPCS,409128331,NDC,facility,both,0.1,ME,,33.44,25.08,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA ESRD 20,000 UNITS/ML SOLN",4000773,CDM,635,RC,Q4081,HCPCS,59676032004,NDC,facility,both,100,UN,,4.47,3.35,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA NON-ESRD 20,000 UNITS/ML SOLN",4000774,CDM,636,RC,J0885,HCPCS,59676032004,NDC,facility,both,1000,UN,,43.41,32.55,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA NON-ESRD 20,000 UNITS/ML SOLN 1 ML VIAL",4000774,CDM,636,RC,J0885,HCPCS,59676032004,NDC,facility,both,1000,UN,,43.59,32.69,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA NON-ESRD 40,000 UNITS/ML SOLN 1 ML VIAL",4000778,CDM,636,RC,J0885,HCPCS,59676034001,NDC,facility,both,1000,UN,,34.62,25.97,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA ESRD 10,000 UNITS/ML SOLN",4000781,CDM,635,RC,Q4081,HCPCS,55513014410,NDC,facility,both,100,UN,,4.82,3.61,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA ESRD 10,000 UNITS/ML SOLN",4000781,CDM,635,RC,Q4081,HCPCS,59676031001,NDC,facility,both,100,UN,,4.27,3.2,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA ESRD 10,000 UNITS/ML SOLN 1 ML VIAL",4000781,CDM,635,RC,Q4081,HCPCS,59676031001,NDC,facility,both,100,UN,,4.27,3.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHARMACY 636,4000781,CDM,636,RC,Q4081,HCPCS,59676031001,NDC,facility,both,100,UN,,4.27,3.2,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA NON-ESRD 10,000 UNITS/ML SOLN",4000782,CDM,636,RC,J0885,HCPCS,59676031001,NDC,facility,both,1000,UN,,42.7,32.02,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA NON-ESRD 2,000 UNITS/ML SOLN",4000784,CDM,636,RC,J0885,HCPCS,55513012610,NDC,facility,both,1000,UN,,71.65,53.74,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML 3 MG/ML,4000799,CDM,250,RC,51079012108,NDC,,,facility,both,0.64,ML,,18.1,13.58,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML 3 MG/ML,4000799,CDM,250,RC,51079012108,NDC,,,facility,both,0.95,ML,,23.55,17.66,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA ESRD 100 MCG/ML SOLN,4000834,CDM,636,RC,J0882,HCPCS,55513000504,NDC,facility,both,1,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA ESRD 100 MCG/ML SOLN,4000834,CDM,636,RC,J0882,HCPCS,55513000504,NDC,facility,both,0.6,ML,,20.05,15.04,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA ESRD 100 MCG/ML SOLN,4000834,CDM,636,RC,J0882,HCPCS,55513000504,NDC,facility,both,1.5,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA ESRD 100 MCG/ML SOLN,4000834,CDM,636,RC,J0882,HCPCS,55513000504,NDC,facility,both,2,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA ESRD 100 MCG/ML SOLN,4000834,CDM,636,RC,J0882,HCPCS,55513000504,NDC,facility,both,0.5,ML,,21.25,15.94,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA ESRD 100 MCG/ML SOLN,4000834,CDM,636,RC,J0882,HCPCS,55513000504,NDC,facility,both,0.4,ML,,22.47,16.85,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA NON-ESRD 100 MCG/ML SOLN,4000835,CDM,636,RC,J0881,HCPCS,55513000504,NDC,facility,both,1.5,ML,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA NON-ESRD 500 MCG/ML SOLN,4000839,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,both,0.08,ML,,23.88,17.91,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA NON-ESRD 500 MCG/ML SOLN,4000839,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,both,1,ML,,17.71,13.28,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA NON-ESRD 500 MCG/ML SOLN,4000839,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,both,0.4,ML,,17.71,13.28,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA NON-ESRD 500 MCG/ML SOLN,4000839,CDM,636,RC,J0881,HCPCS,55513003201,NDC,facility,both,0.3,ML,,17.71,13.28,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,338004918,NDC,facility,both,10,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,J7030,HCPCS,338004903,NDC,facility,both,10,ML,,35.89,26.92,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,990798302,NDC,facility,both,10,ML,,1.49,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,990798436,NDC,facility,both,10,ML,,1.64,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,J7030,HCPCS,990798436,NDC,facility,both,10,ML,,79.55,59.66,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,J7030,HCPCS,338004902,NDC,facility,both,10,ML,,37.75,28.32,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,264780010,NDC,facility,both,10,ML,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,J7030,HCPCS,338004904,NDC,facility,both,10,ML,,40.09,30.06,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,990798437,NDC,facility,both,10,ML,,1.02,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,J7030,HCPCS,990798302,NDC,facility,both,10,ML,,61.64,46.23,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,338004903,NDC,facility,both,10,ML,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,990798303,NDC,facility,both,10,ML,,1.13,0.84,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,264780000,NDC,facility,both,10,ML,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,264780020,NDC,facility,both,10,ML,,0.75,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,338004938,NDC,facility,both,10,ML,,4.33,3.25,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,338004902,NDC,facility,both,10,ML,,1.33,1,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,990798309,NDC,facility,both,10,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,J7030,HCPCS,990798303,NDC,facility,both,10,ML,,58.49,43.87,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,J7030,HCPCS,264780010,NDC,facility,both,10,ML,,6,4.5,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,264180032,NDC,facility,both,10,ML,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,4000852,CDM,250,RC,MHS10ML,HCPCS,338004904,NDC,facility,both,10,ML,,0.38,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 100 ML FLEX CONT,4000852,CDM,250,RC,MHS10ML,HCPCS,338004918,NDC,facility,both,10,ML,,3.66,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 100 ML FLEX CONT,4000852,CDM,250,RC,MHS10ML,HCPCS,264180032,NDC,facility,both,10,ML,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 50 ML FLEX CONT,4000852,CDM,250,RC,J7030,HCPCS,264180031,NDC,facility,both,10,ML,,26.65,19.99,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 500 ML FLEX CONT,4000852,CDM,250,RC,MHS10ML,HCPCS,338004903,NDC,facility,both,10,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % BOLUS SOLN,4000852,CDM,338004904,NDC,,,,,facility,both,10,ML,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,4000853,CDM,636,RC,J7120,HCPCS,990795309,NDC,facility,both,1000,ML,,20.46,15.35,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,4000853,CDM,636,RC,J7120,HCPCS,264775000,NDC,facility,both,1000,ML,,12.92,9.69,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,4000853,CDM,636,RC,J7120,HCPCS,338011704,NDC,facility,both,1000,ML,,15.17,11.38,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,4000853,CDM,636,RC,J7120,HCPCS,338011703,NDC,facility,both,1000,ML,,16.08,12.06,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,4000853,CDM,636,RC,J7120,HCPCS,264775010,NDC,facility,both,1000,ML,,19.5,14.62,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS SOLN,4000853,CDM,636,RC,J7120,HCPCS,409795303,NDC,facility,both,1000,ML,,22.42,16.81,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,4000854,CDM,636,RC,J7060,HCPCS,338001702,NDC,facility,both,500,ML,,13.26,9.95,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,4000854,CDM,636,RC,J7060,HCPCS,338001711,NDC,facility,both,500,ML,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,4000854,CDM,636,RC,J7070,HCPCS,990792209,NDC,facility,both,500,ML,,23.7,17.78,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,4000854,CDM,636,RC,J7060,HCPCS,264751010,NDC,facility,both,500,ML,,18.61,13.96,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,4000854,CDM,636,RC,J7070,HCPCS,338001704,NDC,facility,both,500,ML,,15.51,11.63,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,4000854,CDM,636,RC,J7060,HCPCS,338001703,NDC,facility,both,500,ML,,15.69,11.76,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT",4000854,CDM,636,RC,J7070,HCPCS,338001704,NDC,facility,both,500,ML,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 250 ML FLEX CONT,4000854,CDM,636,RC,J7060,HCPCS,338001702,NDC,facility,both,500,ML,,16.35,12.26,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:1:1,4000856,CDM,250,RC,58657052804,NDC,,,facility,both,30,ML,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:1:1,4000856,CDM,250,RC,58657052804,NDC,,,facility,both,10,ML,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:1:1,4000856,CDM,250,RC,58657052804,NDC,,,facility,both,15,ML,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:1:1,4000856,CDM,250,RC,58657052804,NDC,,,facility,both,20,ML,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:1:1,4000856,CDM,250,RC,58657052804,NDC,,,facility,both,5,ML,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 2.5 MEQ/ML SOLN,4000866,CDM,250,RC,MHS1ML,HCPCS,63323009301,NDC,facility,both,1,ML,,47.3,35.48,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (STERILE) 0.9 % SOLN,4000887,CDM,250,RC,MHS10ML,HCPCS,8290306546,NDC,facility,both,10,ML,,26.06,19.54,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (STERILE) 0.9 % SOLN,4000887,CDM,250,RC,MHS10ML,HCPCS,74107835,NDC,facility,both,10,ML,,30.6,22.95,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (STERILE) 0.9 % SOLN,4000887,CDM,250,RC,MHS10ML,HCPCS,8290306547,NDC,facility,both,10,ML,,27,20.25,,,,,,,,,,Gross Charge Type: Pharmacy
SALINE FLUSH (STERILE) 0.9 % SOLN,4000887,CDM,250,RC,MHS10ML,HCPCS,8290306553,NDC,facility,both,10,ML,,29.2,21.9,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 2 MG/ML 2 MG/ML,4000897,CDM,250,RC,378668977,NDC,,,facility,both,20,ML,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 2 MG/ML 2 MG/ML,4000897,CDM,250,RC,378668977,NDC,,,facility,both,10,ML,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
CEFOXITIN,4000904,CDM,636,RC,J0694,HCPCS,44567024525,NDC,facility,both,1,GM,,75.25,56.44,,,,,,,,,,Gross Charge Type: Pharmacy
CEFOXITIN,4000904,CDM,636,RC,J0694,HCPCS,143987825,NDC,facility,both,1,GM,,73.9,55.42,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,4001028,CDM,636,RC,J1644,HCPCS,63323051877,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,4001028,CDM,636,RC,J1644,HCPCS,409315020,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,4001028,CDM,636,RC,J1644,HCPCS,264957710,NDC,facility,both,1000,UN,,3.64,2.73,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN (FOR HEMODIALYSIS) 1,000 UNITS/ML SOLN",4001034,CDM,636,RC,J1644,HCPCS,63323054015,NDC,facility,both,1000,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10 % SOLN,4001156,CDM,250,RC,MHS1ML,HCPCS,338002302,NDC,facility,both,1,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10 % SOLN,4001156,CDM,250,RC,MHS1ML,HCPCS,338002304,NDC,facility,both,1,ML,,0.02,0.01,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10 % SOLN,4001156,CDM,250,RC,MHS1ML,HCPCS,990793002,NDC,facility,both,1,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,4001215,CDM,636,RC,J1644,HCPCS,409315020,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,4001215,CDM,636,RC,J1644,HCPCS,63323051877,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,4001216,CDM,636,RC,J1644,HCPCS,264957710,NDC,facility,both,1000,UN,,3.64,2.73,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,4001216,CDM,636,RC,J1644,HCPCS,63323052277,NDC,facility,both,1000,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,4001216,CDM,636,RC,J1644,HCPCS,409315020,NDC,facility,both,1000,UN,,2.65,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,4001216,CDM,636,RC,J1644,HCPCS,63323051877,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE (ROCEPHIN) 40 MG/ML IN SW SOLUTION 40 MG/ML,4001251,CDM,636,RC,J0696,HCPCS,409733701,NDC,facility,both,250,ME,,13.66,10.24,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR 100 UNITS/ML SOLN,4001334,CDM,636,RC,J1815,HCPCS,169183311,NDC,facility,both,5,UN,,14.83,11.12,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR 100 UNITS/ML SOLN,4001334,CDM,637,RC,J1815,HCPCS,169183311,NDC,facility,both,5,UN,,15.07,11.31,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % SOLN,4001336,CDM,636,RC,Q9967,HCPCS,270131635,NDC,facility,both,1,ML,,2.5,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML SOLN,4001389,CDM,250,RC,MHS1ML,HCPCS,81033000230,NDC,facility,both,1,ML,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML SOLN,4001389,CDM,250,RC,MHS1ML,HCPCS,68094023161,NDC,facility,both,1,ML,,0.63,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 25 MG/ML SUSR,4001439,CDM,636,RC,J9025,HCPCS,781325394,NDC,facility,both,1,ME,,6.54,4.9,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 25 MG/ML SUSR,4001439,CDM,636,RC,J9025,HCPCS,143960601,NDC,facility,both,1,ME,,2.48,1.86,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 25 MG/ML SUSR,4001439,CDM,636,RC,J9025,HCPCS,16729030610,NDC,facility,both,1,ME,,3.76,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 25 MG/ML SUSR,4001439,CDM,636,RC,J9025,HCPCS,71288011530,NDC,facility,both,1,ME,,1.43,1.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,55.855,ML,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.94,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,23.05,ML,,1.97,1.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.975,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,45.32,ML,,1.03,0.77,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.059,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1074.88,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1975.3,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,228.342,ML,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,41.67,ML,,1.13,0.85,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1571.16,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,819.99,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,103.745,ML,,0.46,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,35.88,ML,,1.32,0.99,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,265.557,ML,,0.18,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.545,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,219.334,ML,,0.22,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.92,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,185.58,ML,,0.26,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,344.41,ML,,0.14,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1060.8,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.51,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,393.315,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,344.264,ML,,0.14,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,262.41,ML,,0.18,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,21.945,ML,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,237.58,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,84.6,ML,,0.56,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,57.545,ML,,0.82,0.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.07,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,193.534,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,45,ML,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,201.73,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,83.69,ML,,0.57,0.43,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.818,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,101.334,ML,,0.47,0.35,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,13.455,ML,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,464.824,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,32.64,ML,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1143.47,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,95.109,ML,,0.5,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2296.4,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,77.415,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,232.48,ML,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1243.7,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,176.109,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,205.41,ML,,0.23,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1236.83,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,174.945,ML,,0.27,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,424.03,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1421.47,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,258.334,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.955,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,953.6,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,168.61,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,97.164,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.86,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1241.05,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,56.2,ML,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,217.685,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1104.5,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1047.15,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,38.82,ML,,1.22,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,536,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,910.315,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,222.4,ML,,0.22,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,153.515,ML,,0.31,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,56.022,ML,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,946.98,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.08,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.83,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,3.265,ML,,11.82,8.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1852.2,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,394.829,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,26,ML,,1.82,1.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,40.7,ML,,1.16,0.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.31,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,511.204,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,320.894,ML,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.549,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,111.28,ML,,0.43,0.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,736.974,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1187.5,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,814.8,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,834.5,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,784.935,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.485,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1.515,ML,,23.62,17.72,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,51.655,ML,,0.91,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,114.25,ML,,0.42,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,368.139,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,977.922,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,776.47,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1204.3,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1315.334,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1008.32,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,974.83,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,255.439,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,593.13,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,18.8,ML,,2.49,1.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.27,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,123.97,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,23.32,ML,,1.97,1.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,50.39,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,53.34,ML,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,26.945,ML,,1.76,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.66,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,44.74,ML,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,105.28,ML,,0.45,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.175,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,22,ML,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,122.75,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,125.62,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1742.1,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,942.3,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,618.32,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1545.292,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,22.96,ML,,2.06,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,112.409,ML,,0.42,0.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.51,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.65,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,34.1,ML,,1.35,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,895.76,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1289.13,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.11,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,551.32,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.16,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,172.3,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,44.549,ML,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,91.37,ML,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,40.48,ML,,1.16,0.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,802.7,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,658.222,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,19.152,ML,,2.37,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.98,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.01,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,126.78,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,572.63,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,56.805,ML,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,636.11,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,57.87,ML,,0.82,0.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,541.93,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,498.11,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,121.48,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,25.34,ML,,1.82,1.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,978.644,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.245,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1716.859,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,37.049,ML,,1.25,0.94,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,964.024,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,794.8,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,250.795,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,692.41,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,474.004,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,51.44,ML,,0.91,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,50.795,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,109.795,ML,,0.43,0.33,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1681.43,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.14,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,55.86,ML,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,871.15,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.959,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,62.64,ML,,0.75,0.57,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,482.73,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,703.698,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,909.38,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,999.049,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1367.26,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,181.285,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,85.1,ML,,0.55,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,16.965,ML,,2.79,2.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.58,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1201.47,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1462.334,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,561.334,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,888.83,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2.045,ML,,15.75,11.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,50.78,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,13.945,ML,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,257.61,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,51.64,ML,,0.91,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.505,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1542.79,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.52,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,800.53,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1093.1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,55.66,ML,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,475.887,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,51.985,ML,,0.91,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,621.08,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,192.094,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,184.34,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,824.66,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,985.944,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,690.6,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,135.765,ML,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.135,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.265,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,73.02,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,525.974,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,420.824,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,22.685,ML,,2.06,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,37.744,ML,,1.25,0.94,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1236.93,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,11.74,ML,,3.94,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,533.314,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,908.47,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,799.329,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,97.885,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,782.659,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,13.015,ML,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,182.245,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,770.664,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,217.534,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,926.435,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,951.47,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,96.495,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,85.059,ML,,0.55,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1700.859,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,126.23,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,838.664,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1238.42,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,128.72,ML,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,125.365,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1541.122,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,956.99,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,645.264,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,35.78,ML,,1.32,0.99,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,800.6,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2296.38,ML,,0.02,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1737.295,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.21,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,805.8,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,915.342,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,160.13,ML,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,830.32,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,69.765,ML,,0.68,0.51,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,714,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,11.2,ML,,3.94,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,475.157,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.73,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,66.38,ML,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.465,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,125.179,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,99.902,ML,,0.48,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,655.985,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,64.115,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,19.022,ML,,2.37,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,200.925,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,20.337,ML,,2.25,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,218.95,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,121.08,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,671.095,ML,,0.07,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,653.95,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,108.23,ML,,0.44,0.33,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,476.8,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.045,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,724.215,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,392.789,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1203.1,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,169.08,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1316.97,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,28.56,ML,,1.63,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,683.9,ML,,0.07,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.62,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,41.135,ML,,1.13,0.85,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,485.03,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,32.725,ML,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1516.334,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,676.074,ML,,0.07,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,152.322,ML,,0.31,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.475,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,56.34,ML,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.215,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.89,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,547.827,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,73.095,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,16,ML,,2.96,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1200.57,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.79,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,899.115,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,913.6,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,67.38,ML,,0.7,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1308.334,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,94.109,ML,,0.5,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,190.987,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.19,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,50.09,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,895.522,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,75.359,ML,,0.63,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,531.53,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,936.334,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,780.515,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,164.865,ML,,0.29,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,86.334,ML,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,64.345,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,25.61,ML,,1.82,1.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,621.97,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,740.1,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,8.515,ML,,5.26,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,250.989,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,22.8,ML,,2.06,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,97.205,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,45.56,ML,,1.03,0.77,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,897.644,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,867.324,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,87.609,ML,,0.54,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,113.664,ML,,0.42,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,55.805,ML,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,86.259,ML,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,975.845,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,357.559,ML,,0.14,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,925.83,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1047.3,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.575,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.97,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1298.792,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.709,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,642.494,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,17.485,ML,,2.63,1.97,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,458.795,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.58,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,632.664,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,119.41,ML,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.1,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.022,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,949.32,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,185.945,ML,,0.26,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.745,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,132.18,ML,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,59.61,ML,,0.79,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,24.53,ML,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,106.044,ML,,0.45,0.33,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,50.8,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,66.415,ML,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,103.75,ML,,0.46,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,620.794,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,74.02,ML,,0.63,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,807.33,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.54,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,687.5,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,244.764,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,180.405,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,388.08,ML,,0.13,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,779.712,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.49,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,68.77,ML,,0.69,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,104.11,ML,,0.45,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,916.137,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,507.65,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,134.114,ML,,0.35,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,274.334,ML,,0.18,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.32,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.21,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1.97,ML,,23.62,17.72,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,138.08,ML,,0.34,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,71.77,ML,,0.66,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.22,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1008.1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,447.19,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,512,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1487.47,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,51.2,ML,,0.91,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1724.095,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.62,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,777.65,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,64.26,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,844.08,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,53.56,ML,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.74,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.69,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.96,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,38.31,ML,,1.22,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,893.844,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1647.83,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,33.83,ML,,1.39,1.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1255.285,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,408.534,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,675.1,ML,,0.07,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,600.704,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.725,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,125.09,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,86.674,ML,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,800.2,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,79.1,ML,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,153.987,ML,,0.31,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,77.7,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,116.5,ML,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,55.645,ML,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,663.329,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,370.537,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,413.764,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,461.122,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,746.65,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,264.327,ML,,0.18,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.48,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,423.43,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,127.345,ML,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1052.5,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,171.15,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,669.85,ML,,0.07,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,184.77,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1792.334,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,94.639,ML,,0.5,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,13.622,ML,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,66.63,ML,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,13.644,ML,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,124.08,ML,,0.38,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,235.394,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,254.96,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.195,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,259.579,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,645.664,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,858.8,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,55.95,ML,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,10.775,ML,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,129.08,ML,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1102.83,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1736.8,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,12.519,ML,,3.64,2.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,232.094,ML,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,378.06,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,28.32,ML,,1.63,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,162.575,ML,,0.29,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,36.8,ML,,1.28,0.96,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,703.902,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,411.3,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.745,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,45.895,ML,,1.03,0.77,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.12,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1527.83,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,29.56,ML,,1.58,1.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,975.9,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1021.644,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,62.78,ML,,0.75,0.57,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,292.1,ML,,0.17,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,781.55,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.23,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,28.2,ML,,1.63,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,57.6,ML,,0.82,0.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,145.334,ML,,0.33,0.25,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,540.324,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,957.1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1468,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,714.47,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,892.334,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,64.4,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,491.33,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,852.644,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,160.604,ML,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.72,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1480.8,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,53.425,ML,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,211.94,ML,,0.23,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.37,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,125.56,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,111.844,ML,,0.43,0.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,107.642,ML,,0.44,0.33,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,754.644,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1552.792,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,736.074,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.44,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,785.765,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1119.3,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,182.8,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,24.21,ML,,1.89,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,204.944,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,872.864,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1238,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,24.32,ML,,1.89,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,83.33,ML,,0.57,0.43,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,799.529,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,101.31,ML,,0.47,0.35,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,635.332,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,908.16,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,80.28,ML,,0.59,0.44,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,59.06,ML,,0.79,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,348.53,ML,,0.14,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,364.5,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,5.98,ML,,7.88,5.91,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,378.08,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,14,ML,,3.38,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,646.75,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,809.83,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,50.54,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,155.955,ML,,0.31,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,886.07,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,80.13,ML,,0.59,0.44,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.92,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,10.065,ML,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,83.04,ML,,0.57,0.43,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,989.672,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1146.8,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,671.11,ML,,0.07,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,215.545,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,298.28,ML,,0.16,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,812.7,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,224.315,ML,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1176.33,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,136.48,ML,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,77.985,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,115.764,ML,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1850.99,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,28.25,ML,,1.63,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.47,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.745,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,359.148,ML,,0.14,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.505,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.49,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,830.018,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,38.565,ML,,1.22,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.022,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,457.349,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,564.094,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,193.46,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,51.02,ML,,0.91,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1361.13,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1117.815,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1572.3,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,45.88,ML,,1.03,0.77,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,31.059,ML,,1.48,1.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1147.3,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,411.65,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.735,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,631.925,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,204.164,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,33.89,ML,,1.39,1.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,124.415,ML,,0.38,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.259,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,264.812,ML,,0.18,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,807.81,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,57.659,ML,,0.82,0.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,477.849,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1542.792,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,888.497,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1305.334,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,389.63,ML,,0.13,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,72.105,ML,,0.65,0.49,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.575,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,36.7,ML,,1.28,0.96,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,126.48,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,113.979,ML,,0.42,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,45.6,ML,,1.03,0.77,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1407.164,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1023.16,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,914.644,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,355.264,ML,,0.14,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,40.64,ML,,1.16,0.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,389.834,ML,,0.13,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,11.21,ML,,3.94,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,371.332,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,35.71,ML,,1.32,0.99,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,117.322,ML,,0.41,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,106.745,ML,,0.45,0.33,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,260.334,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,906.349,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,923.5,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1065.334,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,159.59,ML,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,21.639,ML,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1430.645,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,417.412,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,125.95,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,185.3,ML,,0.26,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,616.795,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,14.73,ML,,3.16,2.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,64.59,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,477.32,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.01,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,6.469,ML,,6.76,5.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,385.41,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,895.534,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.64,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,824.8,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,913.2,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,552.388,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,26.05,ML,,1.76,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,747.074,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,482.23,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,780.805,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1405.23,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.345,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,625.644,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1022.459,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,918.004,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1195.065,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1148.485,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,26.025,ML,,1.76,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2126.935,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1268.145,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,158.987,ML,,0.3,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,919.595,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1144.9,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,7.715,ML,,5.91,4.43,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,121.93,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1155.99,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.31,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1062.815,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,861.385,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,139.987,ML,,0.34,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.58,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,36.28,ML,,1.28,0.96,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1.259,ML,,23.62,17.72,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.785,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,950.945,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,554.65,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,62.95,ML,,0.75,0.57,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.709,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,832.7,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.34,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,39.365,ML,,1.19,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.8,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,101.51,ML,,0.47,0.35,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,160.09,ML,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1197.798,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,716.08,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,937.15,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,459.815,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.26,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,753.5,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1186.16,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,90.775,ML,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,62.015,ML,,0.75,0.57,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,260.97,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,78,ML,,0.61,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1089.38,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.53,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,53.02,ML,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1086.664,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,173.11,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,159.8,ML,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,428.122,ML,,0.11,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,127,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,51.8,ML,,0.91,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.54,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.99,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,51.945,ML,,0.91,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,85.62,ML,,0.55,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,55.16,ML,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,214.53,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,124.179,ML,,0.38,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,128.094,ML,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1024.8,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,164.48,ML,,0.29,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,26.627,ML,,1.76,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,687.63,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,809.3,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,757.544,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,188.2,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,991.835,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,247.029,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.3,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.4,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,993.675,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,975.83,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,104.935,ML,,0.45,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,45.58,ML,,1.03,0.77,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,428.018,ML,,0.11,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,19.04,ML,,2.37,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.99,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,123.58,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,152.315,ML,,0.31,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.97,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,473.844,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1705.019,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,184.545,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1582.174,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,773.675,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,97.63,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,976.3,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,338.52,ML,,0.14,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1282.13,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,149.415,ML,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,104.29,ML,,0.45,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.93,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,696.08,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,261.812,ML,,0.18,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,321.789,ML,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1309.47,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,596.83,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,139.265,ML,,0.34,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,720.402,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1111.985,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,610.314,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.05,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,825.704,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1051.97,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,94.01,ML,,0.5,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,506.43,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,509.1,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1350.23,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2028.32,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.89,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.865,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,29.13,ML,,1.58,1.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,939.18,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,157.945,ML,,0.3,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,703.305,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,94.3,ML,,0.5,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,75.109,ML,,0.63,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,564.17,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,166.109,ML,,0.29,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,972.18,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1393.13,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,444.83,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,79,ML,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,131.255,ML,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.78,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.879,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1567.334,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1.74,ML,,23.62,17.72,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,615.737,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,30.76,ML,,1.53,1.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,64.285,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,390.819,ML,,0.13,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1096.8,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.655,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,76.809,ML,,0.62,0.46,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,74.97,ML,,0.63,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,335.015,ML,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,29.049,ML,,1.58,1.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.61,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,127.15,ML,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1216.32,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1021.989,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1194.97,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,541.644,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,83.53,ML,,0.57,0.43,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,829.53,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1033.32,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,214.28,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1519.334,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,67.659,ML,,0.7,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,852.16,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.305,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,823.33,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,59.235,ML,,0.79,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,197.365,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1060.81,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,463.844,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1154.3,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,490.33,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.32,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1254.08,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,100.534,ML,,0.47,0.35,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,34.715,ML,,1.35,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,303.5,ML,,0.16,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,364.534,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.86,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,18.67,ML,,2.49,1.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.155,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,50.58,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.96,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,217.004,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,535.81,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,30.65,ML,,1.53,1.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.785,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,104.7,ML,,0.45,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,119.355,ML,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,39.415,ML,,1.19,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,162.542,ML,,0.29,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,22.25,ML,,2.06,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,932.497,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,56.37,ML,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,70.395,ML,,0.67,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1239.72,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,235.13,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,360.19,ML,,0.14,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,21.89,ML,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1547.792,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.79,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,13.195,ML,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,64.75,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,606.1,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,122.634,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,464.789,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1356,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,298.41,ML,,0.16,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.33,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,437.072,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1187.57,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,108.818,ML,,0.44,0.33,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,3.692,ML,,11.82,8.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,239.139,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,15.905,ML,,2.96,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,519.23,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,968.13,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,83.595,ML,,0.57,0.43,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,11.275,ML,,3.94,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,797,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,692.56,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,891.334,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,270.614,ML,,0.18,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,319.41,ML,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,57.075,ML,,0.82,0.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,67.19,ML,,0.7,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,34.57,ML,,1.35,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,180.644,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,96.745,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,556.73,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,59.3,ML,,0.79,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,10.37,ML,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,107.515,ML,,0.44,0.33,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1267.065,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.715,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,45.62,ML,,1.03,0.77,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.049,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.08,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,115.265,ML,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1030.004,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.965,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.51,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,41.4,ML,,1.13,0.85,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2124.004,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,85.945,ML,,0.55,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,725.63,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,437.494,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1276.8,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,746.16,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.31,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,771.037,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,804.529,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,66.25,ML,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,212.38,ML,,0.23,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.88,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1094.65,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,334.16,ML,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,27.8,ML,,1.69,1.27,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,181.99,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,466.829,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,59.49,ML,,0.79,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.37,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,6.164,ML,,6.76,5.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,116.02,ML,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,724.334,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,174.294,ML,,0.27,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.62,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,101.015,ML,,0.47,0.35,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,53.44,ML,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,906.08,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,37.14,ML,,1.25,0.94,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,85.015,ML,,0.55,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,89.885,ML,,0.53,0.4,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,151.545,ML,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,192.05,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,50.105,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,44.3,ML,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.112,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,620.334,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,183.85,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,665.664,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.24,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,402.73,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,64.549,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1.809,ML,,23.62,17.72,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1213.69,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,355.515,ML,,0.14,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,943.71,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,182.89,ML,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,420,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1112.065,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,628.974,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,826.359,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,39.68,ML,,1.19,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,348.7,ML,,0.14,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,607.902,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,23.135,ML,,1.97,1.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,967.945,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,588.83,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,246.052,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,218.335,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,125.03,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,50.045,ML,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,170.065,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.44,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,123.65,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,197.259,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,498.78,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,179.22,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,59.89,ML,,0.79,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2200.47,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,55.9,ML,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,215.56,ML,,0.22,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.109,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,410.03,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,300.345,ML,,0.16,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,820.115,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,70.58,ML,,0.67,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,26.515,ML,,1.76,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1159.9,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,501.63,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,972.157,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,135.32,ML,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,824.5,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,497.795,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,812.845,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,224.322,ML,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1437.315,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,251.109,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,893.81,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1622.65,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1136.6,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,738.56,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,39.99,ML,,1.19,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,62.51,ML,,0.75,0.57,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,277.374,ML,,0.17,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1220.83,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,939.32,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,781.015,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1725.99,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,135.22,ML,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,74.75,ML,,0.63,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1166.65,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,649.715,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,305.5,ML,,0.16,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,257.53,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,65.13,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,164.364,ML,,0.29,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,72.88,ML,,0.65,0.49,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,211.244,ML,,0.23,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,707.712,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,881.6,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,380.094,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,150.534,ML,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,566.83,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,75.964,ML,,0.63,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,73.49,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1115.1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,138.45,ML,,0.34,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1244.542,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,545.815,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1045.81,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,849.065,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.91,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,708.985,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,446.11,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,187.552,ML,,0.26,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,85.064,ML,,0.55,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,498.96,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.325,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1116.195,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,3.057,ML,,11.82,8.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1116.235,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.365,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,23.07,ML,,1.97,1.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,465.317,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,17.8,ML,,2.63,1.97,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,56.26,ML,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,71.74,ML,,0.66,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,977.664,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,73.01,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,47.26,ML,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,126.13,ML,,0.38,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,373.094,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,470.08,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,419.824,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,668.664,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,235.36,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.88,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,20.63,ML,,2.25,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1419.019,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,987.82,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1214.222,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,315.774,ML,,0.15,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,56.95,ML,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,40.16,ML,,1.16,0.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,92.064,ML,,0.51,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,239.8,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.67,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,44.445,ML,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.39,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.05,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,843.145,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,123.065,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,168.925,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,434.465,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,345.3,ML,,0.14,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1035.615,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,292.5,ML,,0.17,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.81,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,75.05,ML,,0.63,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,85.159,ML,,0.55,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,36.285,ML,,1.28,0.96,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,28.295,ML,,1.63,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,196.764,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,866.914,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,78.875,ML,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,459.65,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1493.8,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1865.827,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1480.534,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,406.61,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,340.08,ML,,0.14,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,19.72,ML,,2.37,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1251.015,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.26,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,408.609,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.865,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,70.95,ML,,0.67,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,132.025,ML,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,172.094,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,148.985,ML,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,278.6,ML,,0.17,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,112.844,ML,,0.42,0.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,54.855,ML,,0.86,0.65,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,316.488,ML,,0.15,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,478.385,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,263.148,ML,,0.18,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,788.145,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,289.61,ML,,0.17,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,256.63,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,898.13,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,977.515,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2.957,ML,,15.77,11.82,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,490.644,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1537.792,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,678.679,ML,,0.07,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1037.815,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,28.565,ML,,1.63,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,166.485,ML,,0.29,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,16.94,ML,,2.79,2.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,31.745,ML,,1.48,1.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,850.81,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,64.39,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,939.945,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.37,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.47,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,265.28,ML,,0.18,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,433.145,ML,,0.11,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,15.24,ML,,2.96,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,176.334,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1111.844,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,945.17,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,846.33,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,837.184,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1149.12,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1064.8,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1651.424,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,70.96,ML,,0.67,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,693.97,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,67.494,ML,,0.7,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,27.96,ML,,1.69,1.27,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.485,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,37.76,ML,,1.25,0.94,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,57.21,ML,,0.82,0.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,283.05,ML,,0.17,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,99.795,ML,,0.48,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,89.485,ML,,0.53,0.4,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1212.324,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,39.385,ML,,1.19,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,57.43,ML,,0.82,0.61,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.36,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,231.23,ML,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,600.73,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,53.05,ML,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,650.75,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,847.485,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,918.672,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,87.642,ML,,0.54,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,40.08,ML,,1.16,0.87,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,93.48,ML,,0.51,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.05,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,485.99,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,116.05,ML,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,75.945,ML,,0.63,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1124.535,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,587.424,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,74.8,ML,,0.63,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,63.42,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,15.48,ML,,2.96,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,509.095,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.6,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,128.11,ML,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,122.43,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,849.65,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,207.134,ML,,0.23,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,642.47,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,744.5,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,97.39,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,434.95,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.5,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,270.557,ML,,0.18,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.33,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,62.87,ML,,0.75,0.57,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,106.465,ML,,0.45,0.33,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1287.63,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,147.764,ML,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,476.827,ML,,0.1,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,332.844,ML,,0.15,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,121.198,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,22.93,ML,,2.06,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.61,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,14.875,ML,,3.16,2.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,156,ML,,0.31,0.23,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,34.764,ML,,1.35,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,52.549,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,596.925,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,11.625,ML,,3.94,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1140.8,ML,,0.05,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,17.98,ML,,2.63,1.97,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,747.3,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,825,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,61.16,ML,,0.77,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,186.44,ML,,0.26,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,434.394,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,22.11,ML,,2.06,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,517.08,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,196.2,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,81.915,ML,,0.58,0.44,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1179.33,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,49.19,ML,,0.95,0.71,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.445,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1408.615,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,254.08,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,79.595,ML,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,278.53,ML,,0.17,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,140.75,ML,,0.34,0.25,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1616.004,ML,,0.03,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,696.645,ML,,0.07,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,249.96,ML,,0.19,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,520.812,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,104.28,ML,,0.45,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,235.494,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,32.255,ML,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,60.885,ML,,0.78,0.58,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1317.13,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,113.394,ML,,0.42,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,86.15,ML,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,912.83,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,447.66,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,984.004,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,985.83,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,449.824,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,649.059,ML,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.98,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1238.1,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,190.855,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,66.255,ML,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,170.13,ML,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,131.14,ML,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,508.349,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,147.485,ML,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,38.33,ML,,1.22,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,97.48,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1686.334,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,384.388,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,252.979,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,203.617,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,815.212,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,48.705,ML,,0.97,0.73,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,91.61,ML,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,552.965,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2168.645,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,180.21,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1202.965,ML,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,912.374,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,26.55,ML,,1.76,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,497.524,ML,,0.1,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,129.689,ML,,0.37,0.28,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,537.315,ML,,0.09,0.07,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,380.925,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,961.637,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1832.2,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,379.534,ML,,0.13,0.1,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,46.65,ML,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,461.494,ML,,0.11,0.08,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,2071.8,ML,,0.03,0.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,974.65,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,53.21,ML,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,345.864,ML,,0.14,0.11,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,84,ML,,0.57,0.43,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,420.265,ML,,0.12,0.09,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,180.445,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.31,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,42.91,ML,,1.1,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,44.9,ML,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,43.66,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,56.59,ML,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,19.645,ML,,2.37,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,1094.329,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,58.54,ML,,0.81,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,821.644,ML,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",4001561,CDM,250,RC,338001306,NDC,,,facility,both,883.96,ML,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN IN D5W 100 MCG/ML SOLN,4001574,CDM,250,RC,338104702,NDC,,,facility,both,5,ME,,25.15,18.86,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN IN D5W 100 MCG/ML SOLN,4001574,CDM,636,RC,J2305,HCPCS,338104702,NDC,facility,both,5,ME,,25.17,18.88,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE 20 MG/ML SOLN,4001637,CDM,636,RC,J0706,HCPCS,72485010401,NDC,facility,both,5,ME,,3.11,2.33,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 2-0.4 MG/ML 2-0.4 MG/ML SUSP,4001639,CDM,250,RC,703951403,NDC,,,facility,both,10,ML,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 2-0.4 MG/ML 2-0.4 MG/ML SUSP,4001639,CDM,250,RC,703951403,NDC,,,facility,both,1,ML,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 0.02-0.004 MG/ML 0.02-0.004 MG/ML SUSP,4001640,CDM,250,RC,703951403,NDC,,,facility,both,10,ML,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 0.02-0.004 MG/ML 0.02-0.004 MG/ML SUSP,4001640,CDM,250,RC,703951403,NDC,,,facility,both,1,ML,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO (HUMALOG) SQ CARB COUNT & SLIDING SCALE STANDARD 100 UNITS/ML SOLN,4001675,CDM,636,RC,J1815,HCPCS,2753301,NDC,facility,both,5,UN,,25.34,19,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNITS/ML SOLN,4001690,CDM,637,RC,J1815,HCPCS,2751001,NDC,facility,both,5,UN,,18.3,13.72,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNITS/ML SOLN,4001690,CDM,637,RC,J1815,HCPCS,2753301,NDC,facility,both,5,UN,,20.28,15.21,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNITS/ML SOLN,4001690,CDM,636,RC,J1815,HCPCS,2753301,NDC,facility,both,5,UN,,12.82,9.61,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL SOLN,4001728,CDM,636,RC,Q9967,HCPCS,270131535,NDC,facility,both,1,ML,,0.75,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL SOLN,4001728,CDM,636,RC,Q9967,HCPCS,270131525,NDC,facility,both,1,ML,,1.82,1.36,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG/ML 1 MG/ML,4001743,CDM,636,RC,J7507,HCPCS,781210401,NDC,facility,both,1,ME,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,37,ML,,0.48,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,87,ML,,17.18,12.88,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,13,ML,,73.2,54.9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,11,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,22,ML,,0.57,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,1,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,9,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,10,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,10,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,1,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,13.5,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,1,ML,,1.13,0.85,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,33.5,ML,,24.1,18.08,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,10,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,20,ML,,73.2,54.9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,2,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,16.5,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,0.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,4.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,34,ML,,24.1,18.08,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,1.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,15,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,9,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,10,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,1,ML,,1.22,0.92,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,19,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,2.5,ML,,2.26,1.7,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,38,ML,,24.1,18.08,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,7.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,16,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,30,ML,,0.57,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,3,ML,,1.14,0.85,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,18.5,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,4,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,13.5,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,17,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,9.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,3.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,2,ML,,1.22,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,19.5,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,20.5,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,6.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,9,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,12,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,1.2,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,13,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,14,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,10.5,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,22,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,7,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,16,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,5.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,15.5,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,19,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,7,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,8,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,8,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,8,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,6,ML,,1.12,0.84,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,26,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,5.4,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,27,ML,,84.8,63.6,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,18,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,12,ML,,73.2,54.9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,11.5,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,5.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,7,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,3.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,2.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,5.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,4,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,17,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,44,ML,,21.61,16.21,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,3.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,11,ML,,73.2,54.9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,0.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,5,ML,,1.21,0.91,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,3,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,6.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,24,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,16,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,0.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,19,ML,,73.2,54.9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,7.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,0.75,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,2.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,25,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,14,ML,,73.2,54.9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,13.25,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,9,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,0.25,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,1.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,15,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,4,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,3.9,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,2.8,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,28,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,0.6,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,6,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,14,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,27.5,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,1.75,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,2,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,20,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,6,ML,,1.08,0.81,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,781345895,NDC,facility,both,5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,14,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,16.5,ML,,73.2,54.9,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,1.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,15,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,26,ML,,0.57,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,0.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,12.5,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,12,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,31.5,ML,,24.1,18.08,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,3.45,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,24,ML,,0.57,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,8,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,0.8,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,4,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,40,ML,,24.1,18.08,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,12,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,7,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,8.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,8.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,20,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,2,ML,,1.12,0.84,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,21,ML,,84.8,63.6,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,5.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2370,HCPCS,70092104646,NDC,facility,both,9,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,18,ML,,36.6,27.45,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,6,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,11,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,21,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,13,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,1.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,3,ML,,1.27,0.95,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2370,HCPCS,70092104646,NDC,facility,both,2.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,30,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,3,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,both,7.5,ML,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,5.25,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,23,ML,,28.27,21.2,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,70092104646,NDC,,,facility,both,4.5,ML,,57.65,43.24,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 100 MCG/ML SOLN,4001857,CDM,250,RC,J2371,HCPCS,70092104646,NDC,facility,both,17,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G 2.5 MILLION UNIT IN NS 2.5 MILLION UNITS SOLN,4001898,CDM,636,RC,J2540,HCPCS,49052083,NDC,facility,both,0.6,EA,,12.34,9.26,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL (NS) BOLUS SOLN SOLN,4001968,CDM,250,RC,76297000142,NDC,,,facility,both,28.5,ML,,16.1,12.08,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE 0.12 % SOLN 473 ML BOTTLE,4001974,CDM,250,RC,MHS15ML,HCPCS,116200116,NDC,facility,both,15,ML,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,2.442,ML,,1.68,1.26,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,4,ML,,1.28,0.96,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,0.4,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,1.125,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,1.55,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,1.06,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,2.2,ML,,1.68,1.26,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,0.75,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,0.843,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,1.1,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,1.46,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,1.5,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,1.2,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SUSP,4002040,CDM,250,RC,378018401,NDC,,,facility,both,1.758,ML,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % 5 % SOLN,4002065,CDM,636,RC,J7060,HCPCS,264151031,NDC,facility,both,500,ML,,11.5,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % 5 % SOLN,4002065,CDM,636,RC,J7060,HCPCS,338001718,NDC,facility,both,500,ML,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % 5 % SOLN,4002065,CDM,636,RC,J7060,HCPCS,338001711,NDC,facility,both,500,ML,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % 5 % SOLN,4002065,CDM,636,RC,J7060,HCPCS,65219024050,NDC,facility,both,500,ML,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 10,000 UNITS/ML SOLN 1 ML VIAL",4002066,CDM,636,RC,Q5106,HCPCS,69130810,NDC,facility,both,1000,UN,,34.16,25.62,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 40,000 UNITS/ML SOLN",4002074,CDM,636,RC,Q5106,HCPCS,69130904,NDC,facility,both,1000,UN,,27.67,20.76,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 40,000 UNITS/ML SOLN 1 ML VIAL",4002074,CDM,636,RC,Q5105,HCPCS,69130904,NDC,facility,both,1000,UN,,2.93,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 40,000 UNITS/ML SOLN 1 ML VIAL",4002074,CDM,636,RC,Q5106,HCPCS,69130904,NDC,facility,both,1000,UN,,29.87,22.4,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ IN 1000 ML NS 20 MEQ/1000 ML SOLN,4002176,CDM,636,RC,J3480,HCPCS,338069104,NDC,facility,both,1000,ML,,5.16,3.87,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL (BACTERIOSTATIC) 0.9 % SOLN,40022,CDM,250,RC,MHS10ML,HCPCS,409196607,NDC,facility,both,10,ML,,10.12,7.59,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL (BACTERIOSTATIC) 0.9 % SOLN 30 ML VIAL,40022,CDM,250,RC,MHS10ML,HCPCS,63323092403,NDC,facility,both,10,ML,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL (BACTERIOSTATIC) 0.9 % SOLN 30 ML VIAL,40022,CDM,250,RC,MHS10ML,HCPCS,409196607,NDC,facility,both,10,ML,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 5 MG/ML SOLN,4002307,CDM,636,RC,J2250,HCPCS,641606125,NDC,facility,both,1,ME,,9.94,7.45,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 5 MG/ML SOLN,4002307,CDM,636,RC,J2250,HCPCS,409230801,NDC,facility,both,1,ME,,10.01,7.51,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (2 ML) SOLN,4002309,CDM,636,RC,J2250,HCPCS,23155060041,NDC,facility,both,1,ME,,14.56,10.92,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (2 ML) SOLN,4002309,CDM,636,RC,J2250,HCPCS,409230505,NDC,facility,both,1,ME,,6.43,4.82,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (2 ML) SOLN,4002309,CDM,636,RC,J2250,HCPCS,409230517,NDC,facility,both,1,ME,,18.46,13.85,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (5 ML) SOLN,4002310,CDM,636,RC,J2250,HCPCS,409230517,NDC,facility,both,1,ME,,33.15,24.86,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (5 ML) SOLN,4002310,CDM,636,RC,J2250,HCPCS,409230505,NDC,facility,both,1,ME,,11.83,8.87,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,64980033901,NDC,,,facility,both,2,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,10006070028,NDC,,,facility,both,1.05,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,10006070028,NDC,,,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,64980033901,NDC,,,facility,both,1.5,UN,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,10006070028,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,64980033990,NDC,,,facility,both,2,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,64980033901,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,64980033901,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,64980033990,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,64980033901,NDC,,,facility,both,2.5,UN,,2.55,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG TABS,4002315,CDM,250,RC,64980033901,NDC,,,facility,both,1.05,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN 50 MG/ML SOLN,4002427,CDM,250,RC,87040265,NDC,,,facility,both,0.5,ML,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN 50 MG/ML SOLN 50 ML BOTTLE,4002427,CDM,250,RC,87040203,NDC,,,facility,both,0.5,ML,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN 50 MG/ML SOLN 50 ML BOTTLE,4002427,CDM,250,RC,87040203,NDC,,,facility,both,1,ML,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN + IRON 11 MG/ML SOLN,4002428,CDM,250,RC,87040506,NDC,,,facility,both,0.5,ML,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN + IRON 11 MG/ML SOLN 50 ML BOTTLE,4002428,CDM,250,RC,87040501,NDC,,,facility,both,1,ML,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN + IRON 11 MG/ML SOLN 50 ML BOTTLE,4002428,CDM,250,RC,87040501,NDC,,,facility,both,0.5,ML,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN + IRON 11 MG/ML SOLN 50 ML BOTTLE,4002428,CDM,250,RC,87040501,NDC,,,facility,both,0.3,ML,,5.15,3.86,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN *IRON-FREE* TABS,4002433,CDM,250,RC,904053961,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN *IRON-FREE* TABS,4002433,CDM,250,RC,904053061,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN *IRON-FREE* TABS,4002433,CDM,250,RC,904053961,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 20,000 UNITS/ML SOLN",4002468,CDM,636,RC,Q5106,HCPCS,69131110,NDC,facility,both,1000,UN,,26.88,20.16,,,,,,,,,,Gross Charge Type: Pharmacy
"EPOETIN ALFA-EPBX 20,000 UNITS/ML SOLN 1 ML VIAL",4002468,CDM,636,RC,Q5106,HCPCS,69131110,NDC,facility,both,1000,UN,,33.53,25.15,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML,4002477,CDM,636,RC,J1750,HCPCS,23608210,NDC,facility,both,50,ME,,71.2,53.4,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML 2 ML VIAL,4002477,CDM,636,RC,J1750,HCPCS,23608210,NDC,facility,both,50,ME,,71.45,53.59,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN 20 ML VIAL,4002593,CDM,250,RC,J3490,HCPCS,409427601,NDC,facility,both,1,ME,,0.82,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN 30 ML VIAL,4002593,CDM,250,RC,J3490,HCPCS,63323049237,NDC,facility,both,1,ME,,9.72,7.29,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1 % SOLN 5 ML VIAL,4002593,CDM,250,RC,MHS1ML,HCPCS,143959525,NDC,facility,both,1,ME,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 10 MCG/ML 10 MCG/ML,4002662,CDM,250,RC,67457021810,NDC,,,facility,both,0.08,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 10 MCG/ML 10 MCG/ML,4002662,CDM,250,RC,67457021810,NDC,,,facility,both,0.24,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 10 MCG/ML 10 MCG/ML,4002662,CDM,250,RC,67457021810,NDC,,,facility,both,0.32,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 10 MCG/ML 10 MCG/ML,4002662,CDM,250,RC,67457021810,NDC,,,facility,both,0.19,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 10 MCG/ML 10 MCG/ML,4002662,CDM,250,RC,67457021810,NDC,,,facility,both,0.16,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 10 MCG/ML 10 MCG/ML,4002662,CDM,250,RC,67457021810,NDC,,,facility,both,0.38,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 10 MCG/ML 10 MCG/ML,4002662,CDM,250,RC,67457021810,NDC,,,facility,both,0.4,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 10 MCG/ML 10 MCG/ML,4002662,CDM,250,RC,67457021810,NDC,,,facility,both,0.28,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 10 MCG/ML 10 MCG/ML,4002662,CDM,250,RC,67457021810,NDC,,,facility,both,0.09,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID FOR INHALATION 100 MG/ML SOLN,4002677,CDM,250,RC,13111421,NDC,,,facility,both,5,ML,,88.65,66.49,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID FOR INHALATION 100 MG/ML SOLN,4002677,CDM,250,RC,55150018810,NDC,,,facility,both,5,ML,,44.4,33.3,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID FOR INHALATION 100 MG/ML SOLN,4002677,CDM,250,RC,43066000810,NDC,,,facility,both,5,ML,,36.95,27.71,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL (NS) BOLUS SOLN 0.9 % SOLN,4002678,CDM,250,RC,MHS10ML,HCPCS,64253011130,NDC,facility,both,10,ML,,25.64,19.23,,,,,,,,,,Gross Charge Type: Pharmacy
0.9% NACL (NS) BOLUS SOLN 0.9 % SOLN,4002678,CDM,250,RC,MHS10ML,HCPCS,8290306547,NDC,facility,both,10,ML,,9.68,7.26,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,4002723,CDM,250,RC,264780510,NDC,,,facility,both,500,ML,,54.75,41.06,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % SOLN,4002723,CDM,250,RC,63323053075,NDC,,,facility,both,500,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 10 MG/ML SOLN,4002909,CDM,250,RC,42023011310,NDC,,,facility,both,7.5,ML,,89.8,67.35,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 2.5 MG/ML,4002912,CDM,636,RC,J9041,HCPCS,71288011810,NDC,facility,both,0.1,ME,,4.91,3.69,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 2.5 MG/ML,4002912,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,both,0.1,ME,,158.8,119.1,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % SOLN,40069,CDM,636,RC,Q9967,HCPCS,270131525,NDC,facility,both,1,ML,,1.31,0.98,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % SOLN,40069,CDM,255,RC,Q9967,HCPCS,270131525,NDC,facility,both,1,ML,,1.3,0.98,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % SOLN,40069,CDM,636,RC,Q9967,HCPCS,270131535,NDC,facility,both,1,ML,,0.63,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % SOLN,40069,CDM,255,RC,Q9967,HCPCS,270131530,NDC,facility,both,1,ML,,1.09,0.82,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % SOLN,40069,CDM,636,RC,Q9967,HCPCS,270131530,NDC,facility,both,1,ML,,0.91,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % SOLN,40069,CDM,255,RC,Q9967,HCPCS,270131535,NDC,facility,both,1,ML,,0.68,0.51,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.37,ML,,106.55,79.91,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.74,ML,,79.8,59.85,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.81,ML,,82.85,62.14,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.47,ML,,68.2,51.15,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.91,ML,,128.65,96.49,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.4,ML,,65.15,48.86,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.68,ML,,77.25,57.94,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.02,ML,,91.9,68.92,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.71,ML,,78.55,58.91,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.05,ML,,93.2,69.9,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.23,ML,,100.8,75.6,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.14,ML,,53.75,40.31,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.96,ML,,89.3,66.98,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.98,ML,,90.15,67.61,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.94,ML,,88.45,66.34,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.69,ML,,77.65,58.24,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1,ML,,91.05,68.29,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.3,ML,,60.85,45.64,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.01,ML,,91.45,68.59,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.15,ML,,97.5,73.12,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.72,ML,,78.95,59.21,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.06,ML,,93.6,70.2,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.73,ML,,79.4,59.55,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.5,ML,,69.45,52.09,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.44,ML,,66.9,50.18,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.23,ML,,57.8,43.35,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.1,ML,,95.35,71.51,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.83,ML,,83.7,62.78,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.95,ML,,88.9,66.68,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.51,ML,,69.9,52.42,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.16,ML,,97.95,73.46,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.77,ML,,81.1,60.82,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.08,ML,,94.5,70.88,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.79,ML,,82,61.5,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.97,ML,,89.75,67.31,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.84,ML,,84.15,63.11,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.58,ML,,72.9,54.68,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.53,ML,,70.75,53.06,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.45,ML,,67.3,50.48,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.24,ML,,101.2,75.9,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.07,ML,,94.05,70.54,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.13,ML,,53.3,39.98,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.12,ML,,96.2,72.15,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.48,ML,,68.6,51.45,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.59,ML,,73.35,55.01,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.66,ML,,76.35,57.26,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.55,ML,,71.65,53.74,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.25,ML,,101.6,76.2,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.28,ML,,60,45,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.04,ML,,92.75,69.56,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.39,ML,,64.75,48.56,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.94,ML,,129.9,97.42,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.54,ML,,71.2,53.4,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.24,ML,,58.25,43.69,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.03,ML,,92.35,69.26,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.7,ML,,78.1,58.58,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.14,ML,,97.05,72.79,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.75,ML,,80.25,60.19,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.89,ML,,86.3,64.72,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.76,ML,,80.7,60.52,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.41,ML,,65.6,49.2,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.22,ML,,57.35,43.01,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.43,ML,,66.45,49.84,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.35,ML,,63,47.25,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.56,ML,,72.05,54.04,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.82,ML,,83.25,62.44,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.78,ML,,81.55,61.16,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.6,ML,,73.8,55.35,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.34,ML,,62.55,46.91,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.62,ML,,74.65,55.99,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.63,ML,,75.1,56.32,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.52,ML,,70.35,52.76,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.85,ML,,84.55,63.41,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.2,ML,,99.55,74.66,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.8,ML,,82.4,61.8,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,1.13,ML,,96.65,72.49,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.61,ML,,74.2,55.65,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 10 ML SYRINGE,4010005,CDM,250,RC,63323064220,NDC,,,facility,both,0.65,ML,,75.95,56.96,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.53,ML,,70.75,53.06,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.37,ML,,63.85,47.89,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.56,ML,,72.05,54.04,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.39,ML,,64.75,48.56,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.38,ML,,64.3,48.22,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.54,ML,,71.2,53.4,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.55,ML,,71.65,53.74,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.24,ML,,58.25,43.69,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.26,ML,,59.1,44.32,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.34,ML,,62.55,46.91,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.4,ML,,65.15,48.86,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.57,ML,,72.5,54.38,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.59,ML,,73.35,55.01,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.35,ML,,63,47.25,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.31,ML,,61.3,45.98,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.68,ML,,77.25,57.94,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 10 ML SYRINGE,4010006,CDM,250,RC,54482014701,NDC,,,facility,both,0.58,ML,,72.9,54.68,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR (ZOVIRAX) 5 MG/ML IN D5W 5 MG/ML,4010015,CDM,636,RC,J0133,HCPCS,55150015410,NDC,facility,both,5,ME,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR (ZOVIRAX) 5 MG/ML IN NS DILUTION 5 MG/ML,4010015,CDM,636,RC,J0133,HCPCS,55150015410,NDC,facility,both,5,ME,,4.46,3.35,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML SOLN,4010023,CDM,636,RC,J0153,HCPCS,67457085730,NDC,facility,both,1,ME,,1.5,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 1% IN SW DILUTION 1% SOLN,4010024,CDM,636,RC,J0132,HCPCS,517760401,NDC,facility,both,100,ME,,21.17,15.87,,,,,,,,,,Gross Charge Type: Pharmacy
NEONATE STARTER HYPERALIMENTATION SOLN,4010025,CDM,250,RC,72196042801,NDC,,,facility,both,250,ML,,112.75,84.56,,,,,,,,,,Gross Charge Type: Pharmacy
TEMOZOLOMIDE 180 MG CAPS,4010028,CDM,636,RC,J8700,HCPCS,16571082051,NDC,facility,both,5,ME,,1.97,1.48,,,,,,,,,,Gross Charge Type: Pharmacy
CO-ENZYME Q-10 30 MG CAPS,40105,CDM,250,RC,536135807,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 150 MG/ML 750 MG/5ML SUSP,40107,CDM,250,RC,MHS5ML,HCPCS,31722062921,NDC,facility,both,5,ML,,19.13,14.35,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN-HYDROCHLOROTHIAZIDE 50-12.5 MG TABS,40140,CDM,250,RC,93736756,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN-HYDROCHLOROTHIAZIDE 50-12.5 MG TABS,40140,CDM,250,RC,93736756,NDC,,,facility,both,2,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG TABS,4020000,CDM,250,RC,51672402504,NDC,,,facility,both,0.5,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2.5 MG TABS,4020001,CDM,250,RC,13668021730,NDC,,,facility,both,0.5,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 7.5 MG TABS,4020002,CDM,250,RC,13668021930,NDC,,,facility,both,7.5,ME,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 40 MG TABS,4020003,CDM,250,RC,60505008000,NDC,,,facility,both,1,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 40 MG TABS,4020003,CDM,250,RC,60505008000,NDC,,,facility,both,0.5,UN,,6.83,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 6.25 MG TABS,4020004,CDM,250,RC,781805201,NDC,,,facility,both,0.5,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.05 MG TABS,4020005,CDM,250,RC,228212710,NDC,,,facility,both,0.5,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG TABS,4020006,CDM,250,RC,43547040110,NDC,,,facility,both,1,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG TABS,4020006,CDM,250,RC,43547040110,NDC,,,facility,both,2,UN,,1.65,1.24,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG TABS,4020006,CDM,250,RC,43547040110,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 12.5 MG TABS,4020007,CDM,250,RC,16714045201,NDC,,,facility,both,0.5,UN,,5.29,3.97,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 12.5 MG TB24,4020008,CDM,250,RC,55111046601,NDC,,,facility,both,2,UN,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 12.5 MG TB24,4020008,CDM,250,RC,55111046601,NDC,,,facility,both,0.5,UN,,7.39,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 12.5 MG TB24,4020008,CDM,250,RC,55111046601,NDC,,,facility,both,1.5,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 12.5 MG TB24,4020008,CDM,250,RC,55111046601,NDC,,,facility,both,0.49,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 25 MG TABS,4020009,CDM,250,RC,904686861,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 25 MG TABS,4020009,CDM,250,RC,904686861,NDC,,,facility,both,1,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 25 MG TABS,4020009,CDM,250,RC,904686861,NDC,,,facility,both,1.5,UN,,2.37,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 2.5 MG TABS,4020010,CDM,250,RC,51079081020,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 2.5 MG TABS,4020010,CDM,250,RC,51079081020,NDC,,,facility,both,2,UN,,1.71,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 2.5 MG TABS,4020010,CDM,250,RC,51079081020,NDC,,,facility,both,1,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 5 MG TABS,4020011,CDM,250,RC,603240621,NDC,,,facility,both,2,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 5 MG TABS,4020011,CDM,250,RC,63739047910,NDC,,,facility,both,1,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 5 MG TABS,4020011,CDM,250,RC,603240621,NDC,,,facility,both,1,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 5 MG TABS,4020011,CDM,250,RC,603240621,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 1.5 MG TABS,4020012,CDM,250,RC,57896086406,NDC,,,facility,both,1,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 1.5 MG TABS,4020012,CDM,250,RC,20555003601,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 1.5 MG TABS,4020012,CDM,250,RC,57896086406,NDC,,,facility,both,0.5,UN,,5.02,3.77,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 1.5 MG TABS,4020012,CDM,250,RC,20555003601,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 1.5 MG TABS,4020012,CDM,250,RC,57896086406,NDC,,,facility,both,1.5,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 12.5 MG TABS,4020013,CDM,250,RC,378001801,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 12.5 MG TABS,4020013,CDM,250,RC,378001801,NDC,,,facility,both,1,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 12.5 MG TABS,4020013,CDM,250,RC,378001801,NDC,,,facility,both,1.5,UN,,2.17,1.62,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 12.5 MG TABS,4020013,CDM,250,RC,51079025520,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 12.5 MG TABS,4020013,CDM,250,RC,378001801,NDC,,,facility,both,2.5,UN,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 12.5 MG TABS 1 SPLIT TAB BLISTER,4020013,CDM,250,RC,378001801,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 250 MG TABS,4020014,CDM,250,RC,65862000801,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 250 MG TABS,4020014,CDM,250,RC,65862000801,NDC,,,facility,both,1,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 250 MG TABS,4020014,CDM,250,RC,65862000801,NDC,,,facility,both,2,UN,,1.74,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
CEFOXITIN (MEFOXIN) 40 MG/ML IN SW SOLUTION 40 MG/ML,4020017,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,both,1,GM,,62.72,47.04,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,both,3.68,ML,,36.9,27.68,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,2.24,ML,,10.75,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,2.34,ML,,10.85,8.14,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,both,4.32,ML,,38.95,29.21,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,4.07,ML,,7.63,5.72,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,3.9,ML,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,4.15,ML,,7.68,5.76,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,4.77,ML,,8.08,6.06,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,5,ML,,8.23,6.17,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,4.13,ML,,7.67,5.75,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,3.14,ML,,8.79,6.59,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,250,RC,25021012720,NDC,,,facility,both,3.94,ML,,9.42,7.07,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME (FORTAZ) 40 MG/ML IN NS SOLUTION 40 MG/ML,4020018,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,both,4.63,ML,,39.95,29.96,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME (ZINACEF) 25 MG/ML IN NS SOLUTION 25 MG/ML,4020019,CDM,636,RC,J0697,HCPCS,143997790,NDC,facility,both,750,ME,,49.5,37.12,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PEPCID) 0.4 MG/ML IN NS DILUTION 0.4 MG/ML SOLN,4020022,CDM,250,RC,MHS1ML,HCPCS,63323073912,NDC,facility,both,1,ML,,1.78,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 50 MG/ML IN NS 50 MG/ML,4020025,CDM,250,RC,63323036001,NDC,,,facility,both,3.1,ML,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 50 MG/ML IN NS 50 MG/ML,4020025,CDM,250,RC,63323036001,NDC,,,facility,both,2.6,ML,,9.78,7.34,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IN NS PEDS 40 MG/ML,4020026,CDM,250,RC,60505614600,NDC,,,facility,both,2.55,ML,,12.95,9.71,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IN NS PEDS 40 MG/ML,4020026,CDM,250,RC,60505614600,NDC,,,facility,both,2.29,ML,,12.48,9.36,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IN NS PEDS 40 MG/ML,4020026,CDM,250,RC,60505614600,NDC,,,facility,both,1.81,ML,,17.42,13.07,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IN NS PEDS 40 MG/ML,4020026,CDM,250,RC,60505614600,NDC,,,facility,both,37.5,ML,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IN NS PEDS 40 MG/ML,4020026,CDM,250,RC,60505614600,NDC,,,facility,both,0.05,ML,,25.3,18.98,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IN NS PEDS 40 MG/ML,4020026,CDM,250,RC,60505614600,NDC,,,facility,both,2.04,ML,,12.03,9.02,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IN NS PEDS 40 MG/ML,4020026,CDM,250,RC,60505614600,NDC,,,facility,both,3.18,ML,,10.56,7.92,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IN NS PEDS 40 MG/ML,4020026,CDM,250,RC,60505614600,NDC,,,facility,both,50,ML,,2.93,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 20 MG/ML IN NS PEDS 20 MG/ML,4020027,CDM,250,RC,781912585,NDC,,,facility,both,12.5,ML,,5.7,4.28,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 20 MG/ML IN NS PEDS 20 MG/ML,4020027,CDM,250,RC,781912585,NDC,,,facility,both,20,ML,,4.43,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 20 MG/ML IN NS PEDS 20 MG/ML,4020027,CDM,250,RC,781912585,NDC,,,facility,both,2.23,ML,,12.37,9.27,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 20 MG/ML IN NS PEDS 20 MG/ML,4020027,CDM,250,RC,781912585,NDC,,,facility,both,4.32,ML,,9.69,7.27,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 10 MG/ML IN NS 10 MG/ML SOLN,4020033,CDM,636,RC,J1953,HCPCS,67457079000,NDC,facility,both,10,ME,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM (MERREM) 20 MG/ML IN NS PEDS 20 MG/ML,4020034,CDM,636,RC,J2185,HCPCS,55150020830,NDC,facility,both,100,ME,,33.35,25.01,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 0.1 MG/ML IN NS PEDS 0.1 MG/ML SOLN,4020035,CDM,636,RC,J1800,HCPCS,143987201,NDC,facility,both,1,ME,,26.8,20.1,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 0.2 MEQ/ML IN NS (CENTRAL LINE) PEDS 0.2 MEQ/ML SOLN,4020036,CDM,636,RC,J3480,HCPCS,63323096502,NDC,facility,both,15.5,ML,,26.3,19.72,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 0.2 MEQ/ML IN NS (CENTRAL LINE) PEDS 0.2 MEQ/ML SOLN,4020036,CDM,636,RC,J3480,HCPCS,63323096502,NDC,facility,both,15.6,ML,,26.32,19.74,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM (ZOSYN) 40 MG OF PIPERACILLIN/ML IN NS PEDS 40 MG OF PIPERACILLIN/ML,4020038,CDM,636,RC,J2543,HCPCS,781311491,NDC,facility,both,1.125,GM,,60.71,45.54,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 5% IN AQUAPHOR 5 % PSTE,4020039,CDM,250,RC,MHS1GM,HCPCS,245003623,NDC,facility,both,1,GM,,21.5,16.12,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 5% IN AQUAPHOR 5 % PSTE 100 G JAR,4020039,CDM,250,RC,MHS1GM,HCPCS,245003623,NDC,facility,both,1,GM,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 200 MCG/ML 0.2 MG/ML,4020040,CDM,250,RC,MHS5ML,HCPCS,54040441,NDC,facility,both,5,ML,,5.22,3.91,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 7.5MG TABS,4020045,CDM,250,RC,51079008620,NDC,,,facility,both,0.5,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 7.5MG TABS,4020045,CDM,250,RC,13107003134,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 7.5MG TABS,4020045,CDM,250,RC,51079008620,NDC,,,facility,both,1,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 7.5MG TABS,4020045,CDM,250,RC,13107003134,NDC,,,facility,both,0.25,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 7.5MG TABS,4020045,CDM,250,RC,13107003134,NDC,,,facility,both,2,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 7.5MG TABS,4020045,CDM,250,RC,13107003134,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 12.5 MG TABS,4020047,CDM,250,RC,16714008401,NDC,,,facility,both,2,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 12.5 MG TABS,4020047,CDM,250,RC,16714008401,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 12.5 MG TABS,4020047,CDM,250,RC,16714008401,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 2GM/20ML (100 MG/ML) INJ,4020051,CDM,636,RC,J0690,HCPCS,66288110001,NDC,facility,both,500,ME,,450.28,337.71,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL 90 MCG/ACT AERS 18 G INHALER,4020058,CDM,253,RC,MHS1GM,HCPCS,173068220,NDC,facility,both,1,GM,,2.71,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG CAPS,4020059,CDM,253,RC,57237003101,NDC,,,facility,both,21,UN,,0.56,0.42,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 400-57 MG/5ML SUSR 100 ML BOTTLE,4020060,CDM,253,RC,MHS1ML,HCPCS,16714029303,NDC,facility,both,1,ML,,0.27,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR 125 ML BOTTLE,4020061,CDM,253,RC,MHS1ML,HCPCS,93867575,NDC,facility,both,1,ML,,0.65,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG TABS,4020063,CDM,253,RC,69306075,NDC,,,facility,both,6,UN,,5.12,3.84,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,4020065,CDM,253,RC,57237023301,NDC,,,facility,both,14,UN,,0.69,0.51,,,,,,,,,,Gross Charge Type: Pharmacy
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TABS,4020065,CDM,253,RC,57237023301,NDC,,,facility,both,28,UN,,0.41,0.31,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS,4020067,CDM,253,RC,93314701,NDC,,,facility,both,28,UN,,0.7,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG CAPS 28 CAPSULE BOTTLE,4020067,CDM,253,RC,93314701,NDC,,,facility,both,28,UN,,0.7,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG TABS,4020069,CDM,253,RC,70010075401,NDC,,,facility,both,12,UN,,0.88,0.66,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,4020071,CDM,253,RC,65862039010,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG TBDP,4020071,CDM,253,RC,65862039010,NDC,,,facility,both,6,UN,,1.7,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG TABS,4020072,CDM,253,RC,J7512,HCPCS,59746017506,NDC,facility,both,1,ME,,0.08,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG CAPS,4020074,CDM,253,RC,63739056710,NDC,,,facility,both,3,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG TABS,4020075,CDM,253,RC,904600861,NDC,,,facility,both,3,UN,,1.87,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 25 MCG TABS,4020079,CDM,250,RC,59762500701,NDC,,,facility,both,6,UN,,35.65,26.74,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 25 MCG TABS,4020079,CDM,250,RC,59762500701,NDC,,,facility,both,0.25,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 25 MCG TABS,4020079,CDM,250,RC,59762500701,NDC,,,facility,both,0.5,UN,,10.55,7.91,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 25 MCG TABS,4020079,CDM,250,RC,59762500701,NDC,,,facility,both,1,UN,,13.25,9.94,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE MONOHYDRATE 100 MG TABS,4020080,CDM,253,RC,23155013525,NDC,,,facility,both,14,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200-300 MG TABS,4020081,CDM,253,RC,61958070101,NDC,,,facility,both,1,UN,,105.9,79.42,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG TABS,4020082,CDM,253,RC,6022761,NDC,,,facility,both,1,UN,,54,40.5,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:3:2,4020083,CDM,250,RC,58657052804,NDC,,,facility,both,15,ML,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:3:2,4020083,CDM,250,RC,58657052804,NDC,,,facility,both,30,ML,,7.95,5.96,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:3:2,4020083,CDM,250,RC,58657052804,NDC,,,facility,both,7.5,ML,,5.8,4.35,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:3:2,4020083,CDM,250,RC,58657052804,NDC,,,facility,both,10,ML,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ALUMINUM/MAGNESIUM/SIMETHICONE-LIDOCAINE (BMX) 1:3:2,4020083,CDM,250,RC,58657052804,NDC,,,facility,both,20,ML,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 0.5 MG TABS,4020084,CDM,250,RC,832121101,NDC,,,facility,both,2,UN,,1.6,1.2,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 0.5 MG TABS,4020084,CDM,250,RC,832121101,NDC,,,facility,both,2.5,UN,,1.29,0.97,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 0.5 MG TABS,4020084,CDM,250,RC,832121101,NDC,,,facility,both,1,UN,,2.96,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 0.5 MG TABS,4020084,CDM,250,RC,832121101,NDC,,,facility,both,0.5,UN,,6.06,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 0.5 MG TABS,4020084,CDM,250,RC,832121101,NDC,,,facility,both,1.5,UN,,2.1,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM (UNASYN) 30 MG OF AMPICILLIN IN NS DILUTION 30 MG OF AMPICILLIN/ML,4020085,CDM,636,RC,J0295,HCPCS,55150011720,NDC,facility,both,1.5,GM,,78.63,58.98,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE 50 MCG/ML STANDARD PCA 50 MCG/ML SOLN,4020086,CDM,250,RC,70092122335,NDC,,,facility,both,30,ML,,60.1,45.08,,,,,,,,,,Gross Charge Type: Pharmacy
CAPECITABINE 150 MG TABS,4020088,CDM,636,RC,J8520,HCPCS,16729007212,NDC,facility,both,50,ME,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
CAPECITABINE 500 MG TABS,4020089,CDM,636,RC,J8521,HCPCS,72205000792,NDC,facility,both,50,ME,,4.47,3.35,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 50 MG CAPS,4020091,CDM,636,RC,J8530,HCPCS,54038325,NDC,facility,both,25,ME,,10.15,7.62,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 50 MG CAPS,4020092,CDM,636,RC,J8560,HCPCS,378326694,NDC,facility,both,50,ME,,306.7,230.02,,,,,,,,,,Gross Charge Type: Pharmacy
TEMOZOLOMIDE 100 MG CAPS,4020095,CDM,636,RC,J8700,HCPCS,65162080351,NDC,facility,both,5,ME,,5.78,4.33,,,,,,,,,,Gross Charge Type: Pharmacy
TEMOZOLOMIDE 100 MG CAPS,4020095,CDM,636,RC,J8700,HCPCS,47335089221,NDC,facility,both,5,ME,,11.38,8.53,,,,,,,,,,Gross Charge Type: Pharmacy
TEMOZOLOMIDE 140 MG CAPS,4020096,CDM,636,RC,J8700,HCPCS,65162080451,NDC,facility,both,5,ME,,7.04,5.28,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Ophthalmic Us Dx B-Scan W/Wo Non-Quan A-Scan,4027651201,CDM,402,RC,76512,HCPCS,,,facility,both,,,,478,358.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ophthalmic Us Dx B-Scan W/Wo Non-Quan A-Scan,4027651201,CDM,402,RC,76512,HCPCS,,,facility,both,,,,478,358.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Ophthalmic Ultrasonic Foreign Body Localization,4027652901,CDM,402,RC,76529,HCPCS,,,facility,both,,,,312,234,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Ophthalmic Ultrasonic Foreign Body Localization,4027652901,CDM,402,RC,76529,HCPCS,,,facility,both,,,,312,234,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
NAPHAZOLINE-PHENIRAMINE 0.027-0.315 % SOLN 15 ML BOTTLE,40372,CDM,250,RC,MHS1ML,HCPCS,10119002090,NDC,facility,both,1,ML,,2.24,1.68,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG TABS,40389,CDM,250,RC,49348012813,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG TABS,40389,CDM,250,RC,70677110203,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG TABS,40389,CDM,250,RC,904552987,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG TABS,40389,CDM,250,RC,904552952,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG TABS,40389,CDM,250,RC,49348012813,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG TABS,40389,CDM,250,RC,70677110203,NDC,,,facility,both,4,UN,,2.1,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG TABS,40389,CDM,250,RC,49348012813,NDC,,,facility,both,4,UN,,2.01,1.51,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG TABS,40389,CDM,250,RC,70677110203,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 10 MG TABS,40389,CDM,250,RC,49348012812,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 G SOLR,4043,CDM,636,RC,J0688,HCPCS,143992490,NDC,facility,both,500,ME,,15.05,11.29,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 G SOLR,4043,CDM,636,RC,J0690,HCPCS,143992490,NDC,facility,both,500,ME,,14.72,11.04,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 G SOLR,4043,CDM,636,RC,J0690,HCPCS,44567070725,NDC,facility,both,500,ME,,18.4,13.8,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 G SOLR,4043,CDM,636,RC,J0690,HCPCS,143926225,NDC,facility,both,500,ME,,8.47,6.35,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 G SOLR,4043,CDM,636,RC,J0690,HCPCS,60505614205,NDC,facility,both,500,ME,,17.6,13.2,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 G SOLR 1 EACH VIAL,4043,CDM,636,RC,J0690,HCPCS,143992490,NDC,facility,both,500,ME,,18.45,13.84,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1 G SOLR 1 EACH VIAL,4043,CDM,636,RC,J0690,HCPCS,143926225,NDC,facility,both,500,ME,,14.88,11.16,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SOLR 1 EACH VIAL,4044,CDM,636,RC,J0688,HCPCS,143998303,NDC,facility,both,500,ME,,26.4,19.8,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,50268081615,NDC,,,facility,both,2,UN,,5.12,3.84,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,68462013001,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,68462013001,NDC,,,facility,both,3,UN,,2.87,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,60687023001,NDC,,,facility,both,2,UN,,4.98,3.73,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,60687023001,NDC,,,facility,both,1,UN,,6.28,4.71,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,50268081615,NDC,,,facility,both,4,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,50268081615,NDC,,,facility,both,1,UN,,8.77,6.58,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,60687023001,NDC,,,facility,both,3,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,50268081615,NDC,,,facility,both,3,UN,,3.83,2.87,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG CAPS,40467,CDM,250,RC,50268081615,NDC,,,facility,both,5,UN,,2.77,2.08,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE MOFETIL 250 MG CAPS,40486,CDM,636,RC,J7517,HCPCS,93733401,NDC,facility,both,250,ME,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,J7030,HCPCS,264780020,NDC,facility,both,10,ML,,46.2,34.65,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,338004918,NDC,facility,both,10,ML,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,J7030,HCPCS,338004902,NDC,facility,both,10,ML,,36.55,27.41,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798437,NDC,facility,both,10,ML,,2.2,1.65,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,J7030,HCPCS,990798303,NDC,facility,both,10,ML,,59.65,44.74,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798361,NDC,facility,both,10,ML,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,J7030,HCPCS,990798302,NDC,facility,both,10,ML,,61.55,46.16,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798309,NDC,facility,both,10,ML,,0.63,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,J7030,HCPCS,338004903,NDC,facility,both,10,ML,,36.55,27.41,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,J7030,HCPCS,338004904,NDC,facility,both,10,ML,,38.12,28.59,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,338004904,NDC,facility,both,10,ML,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,338004903,NDC,facility,both,10,ML,,0.71,0.53,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798303,NDC,facility,both,10,ML,,1.18,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798302,NDC,facility,both,10,ML,,2.18,1.64,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798423,NDC,facility,both,10,ML,,2.48,1.86,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798436,NDC,facility,both,10,ML,,2.89,2.17,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,338004902,NDC,facility,both,10,ML,,1.37,1.03,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN,40620,CDM,250,RC,J7030,HCPCS,990798309,NDC,facility,both,10,ML,,63.5,47.62,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9 % NACL 0.9 % SOLN 1,000 ML FLEX CONT",40620,CDM,250,RC,J7030,HCPCS,338004904,NDC,facility,both,10,ML,,40.4,30.3,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9 % NACL 0.9 % SOLN 1,000 ML FLEX CONT",40620,CDM,250,RC,MHS10ML,HCPCS,338004904,NDC,facility,both,10,ML,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9 % NACL 0.9 % SOLN 1,000 ML FLEX CONT",40620,CDM,250,RC,J7030,HCPCS,264780000,NDC,facility,both,10,ML,,40.4,30.3,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9 % NACL 0.9 % SOLN 1,000 ML FLEX CONT",40620,CDM,250,RC,MHS10ML,HCPCS,264780009,NDC,facility,both,10,ML,,0.48,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004948,NDC,facility,both,10,ML,,3.66,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338004938,NDC,facility,both,10,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,264180032,NDC,facility,both,10,ML,,46.35,34.76,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338004918,NDC,facility,both,10,ML,,36.57,27.43,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338004948,NDC,facility,both,10,ML,,36.55,27.41,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,264180032,NDC,facility,both,10,ML,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004938,NDC,facility,both,10,ML,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004918,NDC,facility,both,10,ML,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 150 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,990798361,NDC,facility,both,10,ML,,61.94,46.45,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 150 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,990798361,NDC,facility,both,10,ML,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338004902,NDC,facility,both,10,ML,,36.54,27.4,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,264780020,NDC,facility,both,10,ML,,45.72,34.29,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,990798302,NDC,facility,both,10,ML,,61.55,46.16,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004902,NDC,facility,both,10,ML,,1.45,1.09,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,990798302,NDC,facility,both,10,ML,,2.46,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,264780020,NDC,facility,both,10,ML,,1.81,1.35,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 50 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,264180031,NDC,facility,both,10,ML,,41.2,30.9,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 50 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338055311,NDC,facility,both,10,ML,,50.4,37.8,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 50 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338915130,NDC,facility,both,10,ML,,52.57,39.43,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 500 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338004903,NDC,facility,both,10,ML,,36.55,27.41,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 500 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,264780010,NDC,facility,both,10,ML,,51.06,38.3,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 500 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004903,NDC,facility,both,10,ML,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 500 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,264780010,NDC,facility,both,10,ML,,0.99,0.75,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL 0.9 % SOLN 500 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,990798303,NDC,facility,both,10,ML,,59.65,44.74,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798303,NDC,facility,both,10,ML,,1.19,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798309,NDC,facility,both,10,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,338004904,NDC,facility,both,10,ML,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9 % NACL SOLN 1,000 ML FLEX CONT",40620,CDM,250,RC,MHS10ML,HCPCS,338004904,NDC,facility,both,10,ML,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9 % NACL SOLN 1,000 ML FLEX CONT",40620,CDM,250,RC,MHS10ML,HCPCS,264780009,NDC,facility,both,10,ML,,0.48,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
"0.9 % NACL SOLN 1,000 ML FLEX CONT",40620,CDM,250,RC,MHS10ML,HCPCS,264780000,NDC,facility,both,10,ML,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,990798437,NDC,facility,both,10,ML,,3.74,2.8,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004938,NDC,facility,both,10,ML,,3.47,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004918,NDC,facility,both,10,ML,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,264180032,NDC,facility,both,10,ML,,4.03,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 150 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,990798361,NDC,facility,both,10,ML,,3.67,2.75,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 250 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,990798302,NDC,facility,both,10,ML,,2.46,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 250 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,264780020,NDC,facility,both,10,ML,,1.69,1.27,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 250 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004902,NDC,facility,both,10,ML,,1.39,1.04,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 50 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,990798436,NDC,facility,both,10,ML,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 500 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004903,NDC,facility,both,10,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
0.9 % NACL SOLN 500 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,264780010,NDC,facility,both,10,ML,,0.96,0.72,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798302,NDC,facility,both,10,ML,,2.46,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798303,NDC,facility,both,10,ML,,1.19,0.89,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,338004918,NDC,facility,both,10,ML,,1.94,1.45,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,338004904,NDC,facility,both,10,ML,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,990798437,NDC,facility,both,10,ML,,3.74,2.8,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN,40620,CDM,250,RC,MHS10ML,HCPCS,338004903,NDC,facility,both,10,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
"NACL 0.9 % SOLN 1,000 ML FLEX CONT",40620,CDM,250,RC,MHS10ML,HCPCS,338004904,NDC,facility,both,10,ML,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004948,NDC,facility,both,10,ML,,3.66,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,264180032,NDC,facility,both,10,ML,,41.2,30.9,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,264180032,NDC,facility,both,10,ML,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338004918,NDC,facility,both,10,ML,,35.8,26.85,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 100 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004918,NDC,facility,both,10,ML,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 150 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,990798361,NDC,facility,both,10,ML,,4.13,3.1,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338004902,NDC,facility,both,10,ML,,35.12,26.34,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004902,NDC,facility,both,10,ML,,1.37,1.03,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,264780020,NDC,facility,both,10,ML,,1.73,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 250 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,990798302,NDC,facility,both,10,ML,,61.55,46.16,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 500 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,338004903,NDC,facility,both,10,ML,,0.73,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 500 ML FLEX CONT,40620,CDM,250,RC,J7030,HCPCS,338004903,NDC,facility,both,10,ML,,36.55,27.41,,,,,,,,,,Gross Charge Type: Pharmacy
NACL 0.9 % SOLN 500 ML FLEX CONT,40620,CDM,250,RC,MHS10ML,HCPCS,264780010,NDC,facility,both,10,ML,,0.96,0.72,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLN,40620,CDM,338004904,NDC,,,,,facility,both,10,ML,,31.17,23.38,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLN,40620,CDM,264180032,NDC,,,,,facility,both,10,ML,,43.48,32.61,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 37.5 MG CP24,40653,CDM,250,RC,68084069801,NDC,,,facility,both,1,UN,,7.83,5.87,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 37.5 MG CP24,40653,CDM,250,RC,68084069801,NDC,,,facility,both,2,UN,,4.9,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 37.5 MG CP24,40653,CDM,250,RC,68084069801,NDC,,,facility,both,3,UN,,3.62,2.71,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 37.5 MG CP24,40653,CDM,250,RC,68084069801,NDC,,,facility,both,4,UN,,2.96,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG CP24,40657,CDM,250,RC,68084070901,NDC,,,facility,both,4,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG CP24,40657,CDM,250,RC,68084070901,NDC,,,facility,both,1,UN,,8.52,6.39,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG CP24,40657,CDM,250,RC,68084070901,NDC,,,facility,both,3,UN,,3.73,2.8,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG CP24,40657,CDM,250,RC,68084070901,NDC,,,facility,both,1.5,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG CP24,40657,CDM,250,RC,68084070901,NDC,,,facility,both,2,UN,,5.02,3.77,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 75 MG CP24,40657,CDM,250,RC,68084070901,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG CP24,40658,CDM,250,RC,68084071301,NDC,,,facility,both,0.5,UN,,3.03,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG CP24,40658,CDM,250,RC,68084071301,NDC,,,facility,both,1.5,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG CP24,40658,CDM,250,RC,68084071301,NDC,,,facility,both,1.25,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG CP24,40658,CDM,250,RC,68084071301,NDC,,,facility,both,1,UN,,7.81,5.86,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG CP24,40658,CDM,250,RC,904707661,NDC,,,facility,both,1,UN,,6.62,4.97,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG CP24,40658,CDM,250,RC,68084071301,NDC,,,facility,both,2,UN,,5,3.75,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG CP24,40658,CDM,250,RC,68084071301,NDC,,,facility,both,0.75,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 7 MG/24HR PT24,40659,CDM,250,RC,60505706400,NDC,,,facility,both,1,UN,,24.15,18.11,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24HR PT24,40661,CDM,250,RC,60505706500,NDC,,,facility,both,1,UN,,24.15,18.11,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24HR PT24,40661,CDM,250,RC,43598044770,NDC,,,facility,both,1,UN,,23.9,17.92,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24HR PT24,40663,CDM,250,RC,536589688,NDC,,,facility,both,1,UN,,23.8,17.85,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24HR PT24,40663,CDM,250,RC,60505706600,NDC,,,facility,both,1,UN,,24.15,18.11,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24HR PT24,40663,CDM,250,RC,60505709000,NDC,,,facility,both,2,UN,,13.9,10.42,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24HR PT24,40663,CDM,250,RC,43598044870,NDC,,,facility,both,1,UN,,23.75,17.81,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24HR PT24,40663,CDM,250,RC,60505709000,NDC,,,facility,both,1,UN,,24.15,18.11,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 8.8 MG/5ML SYRP,40670,CDM,250,RC,MHS1ML,HCPCS,39328022015,NDC,facility,both,1,ML,,1.29,0.96,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 8.8 MG/5ML SYRP,40670,CDM,250,RC,MHS1ML,HCPCS,48433021940,NDC,facility,both,1,ML,,4.37,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 8.8 MG/5ML SYRP,40670,CDM,250,RC,MHS1ML,HCPCS,536126659,NDC,facility,both,1,ML,,0.92,0.69,,,,,,,,,,Gross Charge Type: Pharmacy
VISCOUS LIDOCAINE 2 % SOLN,40856,CDM,250,RC,121495015,NDC,,,facility,both,15,ML,,13.15,9.86,,,,,,,,,,Gross Charge Type: Pharmacy
VISCOUS LIDOCAINE 2 % SOLN,40856,CDM,250,RC,121495040,NDC,,,facility,both,15,ML,,13.15,9.86,,,,,,,,,,Gross Charge Type: Pharmacy
VISCOUS LIDOCAINE 2 % SOLN,40856,CDM,250,RC,62135071242,NDC,,,facility,both,15,ML,,180.1,135.08,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 25 MCG/HR PT72,40873,CDM,250,RC,47781042447,NDC,,,facility,both,1,UN,,9.75,7.31,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 25 MCG/HR PT72,40873,CDM,250,RC,60505708102,NDC,,,facility,both,1,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/HR PT72,40874,CDM,250,RC,406915076,NDC,,,facility,both,1,UN,,23.6,17.7,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/HR PT72,40874,CDM,250,RC,378912298,NDC,,,facility,both,1,UN,,30.75,23.06,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 50 MCG/HR PT72,40874,CDM,250,RC,47781042647,NDC,,,facility,both,1,UN,,12.85,9.64,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 75 MCG/HR PT72,40875,CDM,250,RC,378912398,NDC,,,facility,both,1,UN,,32.95,24.71,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 75 MCG/HR PT72,40875,CDM,250,RC,47781042747,NDC,,,facility,both,1,UN,,23.5,17.62,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 75 MCG/HR PT72,40875,CDM,250,RC,406917576,NDC,,,facility,both,1,UN,,34,25.5,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR PT72,40876,CDM,250,RC,47781042847,NDC,,,facility,both,1,UN,,27.95,20.96,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR PT72,40876,CDM,250,RC,60505708400,NDC,,,facility,both,1,UN,,32.25,24.19,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR PT72,40876,CDM,250,RC,47781042847,NDC,,,facility,both,2,UN,,24.88,18.66,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR PT72,40876,CDM,250,RC,60505700902,NDC,,,facility,both,2,UN,,40.22,30.17,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML STANDARD PCA 1 MG/ML SOLN,4090004,CDM,636,RC,J2270,HCPCS,70092161379,NDC,facility,both,10,ME,,42.61,31.96,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML STANDARD PCA 1 MG/ML SOLN,4090004,CDM,636,RC,J2270,HCPCS,641612701,NDC,facility,both,10,ME,,13.17,9.87,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 1 MG/ML IN NS (ADULT OPIATE NAIVE) PCA 1 MG/ML,4090014,CDM,636,RC,J1170,HCPCS,71449001832,NDC,facility,both,0.1,ME,,13.51,10.13,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 1 MG/ML OPIOID TOLERANT ADULT PCA 1 MG/ML,4090014,CDM,636,RC,J1170,HCPCS,71449001832,NDC,facility,both,0.1,ME,,13.51,10.13,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TABS,40966,CDM,250,RC,55111029136,NDC,,,facility,both,1,UN,,11.25,8.44,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TABS,40966,CDM,250,RC,16714079601,NDC,,,facility,both,1,UN,,10.1,7.58,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TABS,40966,CDM,250,RC,55111029136,NDC,,,facility,both,2,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TABS,40966,CDM,250,RC,16714079601,NDC,,,facility,both,2,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TABS,40967,CDM,250,RC,16714079701,NDC,,,facility,both,2,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TABS,40967,CDM,250,RC,65862014736,NDC,,,facility,both,1,UN,,11.5,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TABS,40967,CDM,250,RC,65862014736,NDC,,,facility,both,2,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TABS,40967,CDM,250,RC,16714079701,NDC,,,facility,both,1,UN,,11.45,8.59,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TABS,40967,CDM,250,RC,55111029236,NDC,,,facility,both,1,UN,,10.4,7.8,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TABS,40967,CDM,250,RC,55111029236,NDC,,,facility,both,2,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 50 MG TBEC,40985,CDM,250,RC,60687060611,NDC,,,facility,both,1.5,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 50 MG TBEC,40985,CDM,250,RC,60687060611,NDC,,,facility,both,1,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 75 MG TBEC,40986,CDM,250,RC,16571020110,NDC,,,facility,both,1,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
MULTI-VITAMIN GUMMIES CHEW,4101006,CDM,250,RC,2791701471,NDC,,,facility,both,1,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
AYR SALINE NASAL GEL 14.1 G TUBE,41048,CDM,250,RC,225052547,NDC,,,facility,both,14.1,GR,,11.1,8.32,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 200MG/20ML SOLR 1 EACH VIAL,41136,CDM,636,RC,J0640,HCPCS,143955301,NDC,facility,both,50,ME,,6,4.5,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 200MG/20ML SOLR 1 EACH VIAL,41136,CDM,636,RC,J0640,HCPCS,71288016230,NDC,facility,both,50,ME,,18.56,13.92,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 200MG/20ML SOLR 1 EACH VIAL,41136,CDM,636,RC,J0640,HCPCS,63323071050,NDC,facility,both,50,ME,,11.27,8.45,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 200MG/20ML SOLR 1 EACH VIAL,41136,CDM,636,RC,J0640,HCPCS,67457052920,NDC,facility,both,50,ME,,28.1,21.07,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,41136,CDM,636,RC,J0640,HCPCS,143955301,NDC,facility,both,50,ME,,6.48,4.86,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,41136,CDM,636,RC,J0640,HCPCS,63323071050,NDC,facility,both,50,ME,,12.45,9.34,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,41136,CDM,636,RC,J0640,HCPCS,71288016230,NDC,facility,both,50,ME,,15.19,11.39,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,41136,CDM,636,RC,J0640,HCPCS,25021081530,NDC,facility,both,50,ME,,11.38,8.53,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN SOLR 1 EACH VIAL,41136,CDM,636,RC,J0640,HCPCS,67457052920,NDC,facility,both,50,ME,,13.73,10.3,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN LIQD,4114,CDM,250,RC,5434462,NDC,,,facility,both,15,ML,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN LIQD,4114,CDM,250,RC,68094012061,NDC,,,facility,both,15,ML,,10.2,7.65,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN LIQD,4114,CDM,250,RC,81033050150,NDC,,,facility,both,15,ML,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE 0.5 % SOLN,41225,CDM,250,RC,23040330,NDC,,,facility,both,0.266666667,UN,,23.95,17.96,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE 0.5 % SOLN,41225,CDM,250,RC,49348032944,NDC,,,facility,both,0.066666667,UN,,23.8,17.85,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE 0.5 % SOLN,41225,CDM,250,RC,23040330,NDC,,,facility,both,0.133333333,UN,,23.9,17.92,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE 0.5 % SOLN,41225,CDM,250,RC,23040330,NDC,,,facility,both,0.066666667,UN,,23.85,17.89,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE 0.5 % SOLN,41225,CDM,250,RC,49348032944,NDC,,,facility,both,0.133333333,UN,,23.85,17.89,,,,,,,,,,Gross Charge Type: Pharmacy
POLYVINYL ALCOHOL 1.4 % SOLN 15 ML BOTTLE,41228,CDM,250,RC,MHS1ML,HCPCS,50268067815,NDC,facility,both,1,ML,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE 15 GM/60ML SUSP,41238,CDM,250,RC,MHS1ML,HCPCS,46287000660,NDC,facility,both,1,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
"GELATIN, ADSORBABLE 12-7 MM MISC",41405,CDM,250,RC,9031508,NDC,,,facility,both,2,UN,,25.42,19.07,,,,,,,,,,Gross Charge Type: Pharmacy
"GELATIN, ADSORBABLE 12-7 MM MISC",41405,CDM,250,RC,9031508,NDC,,,facility,both,1,UN,,43.95,32.96,,,,,,,,,,Gross Charge Type: Pharmacy
GELATIN ADSORBABLE 50 MISC,41432,CDM,250,RC,9032301,NDC,,,facility,both,3,UN,,32.83,24.62,,,,,,,,,,Gross Charge Type: Pharmacy
GELATIN ADSORBABLE 50 MISC,41432,CDM,250,RC,9032301,NDC,,,facility,both,2,UN,,39.3,29.48,,,,,,,,,,Gross Charge Type: Pharmacy
GELATIN ADSORBABLE 50 MISC,41432,CDM,250,RC,9032301,NDC,,,facility,both,1,UN,,58.7,44.02,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 5000 UNIT CAPS,41508,CDM,250,RC,80681013100,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 5000 UNIT CAPS,41508,CDM,250,RC,50268086815,NDC,,,facility,both,2,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 5000 UNIT CAPS,41508,CDM,250,RC,50268086815,NDC,,,facility,both,1,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 5000 UNIT CAPS,41508,CDM,250,RC,53191024401,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 5000 UNIT CAPS,41508,CDM,250,RC,50268086815,NDC,,,facility,both,3,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE 250 MG TABS,41591,CDM,250,RC,43292055606,NDC,,,facility,both,2.4,UN,,2.12,1.59,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE 250 MG TABS,41591,CDM,250,RC,43292055606,NDC,,,facility,both,5,UN,,1.34,1,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE 250 MG TABS,41591,CDM,250,RC,43292055606,NDC,,,facility,both,4,UN,,1.64,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE 250 MG TABS,41591,CDM,250,RC,43292055606,NDC,,,facility,both,2,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE 250 MG TABS,41591,CDM,250,RC,43292055606,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE 250 MG TABS,41591,CDM,250,RC,43292055606,NDC,,,facility,both,3,UN,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE 250 MG TABS,41591,CDM,250,RC,43292055606,NDC,,,facility,both,4.8,UN,,1.33,1,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 120 MG TABS,41616,CDM,250,RC,60505015900,NDC,,,facility,both,1,UN,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN 200 UNIT/ACT SOLN 3.7 ML BOTTLE,41644,CDM,250,RC,60505082306,NDC,,,facility,both,3.7,ML,,62.15,46.61,,,,,,,,,,Gross Charge Type: Pharmacy
BICALUTAMIDE 50 MG TABS,41656,CDM,250,RC,16714081601,NDC,,,facility,both,1,UN,,37.3,27.98,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 40 MG/ML SUSR,41771,CDM,250,RC,MHS5ML,HCPCS,59762314001,NDC,facility,both,5,ML,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5ML SYRP,41818,CDM,250,RC,MHS5ML,HCPCS,69339015019,NDC,facility,both,5,ML,,5,3.75,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5ML SYRP,41818,CDM,250,RC,MHS5ML,HCPCS,121127600,NDC,facility,both,5,ML,,4.49,3.37,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF) 1 MG/ML SOLN,41900,CDM,636,RC,J2274,HCPCS,409381512,NDC,facility,both,10,ME,,52.46,39.34,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF) 1 MG/ML SOLN 10 ML VIAL,41900,CDM,636,RC,J2274,HCPCS,409381512,NDC,facility,both,10,ME,,47.39,35.54,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN IN D5W 200 MCG/ML SOLN,41913,CDM,250,RC,338104902,NDC,,,facility,both,5,ME,,72.5,54.38,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN IN D5W 200 MCG/ML SOLN,41913,CDM,636,RC,J2305,HCPCS,338104902,NDC,facility,both,5,ME,,7.23,5.42,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN IN D5W 200 MCG/ML SOLN 250 ML GLASS CONT,41913,CDM,636,RC,J2305,HCPCS,338104902,NDC,facility,both,5,ME,,7.26,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN IN D5W 200 MCG/ML SOLN 250 ML GLASS CONT,41913,CDM,250,RC,338104902,NDC,,,facility,both,5,ME,,72.52,54.39,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.45% NACL SOLN,41922,CDM,250,RC,MHS500ML,HCPCS,990792609,NDC,facility,both,500,ML,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.45% NACL SOLN,41922,CDM,250,RC,MHS500ML,HCPCS,338008503,NDC,facility,both,500,ML,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.45% NACL SOLN,41922,CDM,250,RC,MHS500ML,HCPCS,409792603,NDC,facility,both,500,ML,,24.7,18.52,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.45% NACL SOLN,41922,CDM,250,RC,MHS500ML,HCPCS,338008504,NDC,facility,both,500,ML,,8.7,6.53,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 % AND 0.45% NACL SOLN 1,000 ML FLEX CONT",41922,CDM,250,RC,MHS500ML,HCPCS,338008504,NDC,facility,both,500,ML,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 % AND 0.45% NACL SOLN 1,000 ML FLEX CONT",41922,CDM,250,RC,MHS500ML,HCPCS,990792609,NDC,facility,both,500,ML,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.9% NACL SOLN,41985,CDM,636,RC,J7042,HCPCS,338008904,NDC,facility,both,500,ML,,8.69,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.9% NACL SOLN,41985,CDM,636,RC,J7042,HCPCS,990794109,NDC,facility,both,500,ML,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 % AND 0.9% NACL SOLN 1,000 ML FLEX CONT",41985,CDM,636,RC,J7042,HCPCS,338008904,NDC,facility,both,500,ML,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 % AND 0.9% NACL SOLN 1,000 ML FLEX CONT",41985,CDM,636,RC,J7042,HCPCS,990794109,NDC,facility,both,500,ML,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
ACARBOSE 50 MG TABS,42005,CDM,250,RC,64380075906,NDC,,,facility,both,0.5,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
EPOPROSTENOL SOLR 1 EACH VIAL,42010,CDM,636,RC,J1325,HCPCS,66215040201,NDC,facility,both,0.5,ME,,70.15,52.61,,,,,,,,,,Gross Charge Type: Pharmacy
EPOPROSTENOL SOLR 1 EACH VIAL,42010,CDM,636,RC,J1325,HCPCS,62756006040,NDC,facility,both,0.5,ME,,50.34,37.75,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.25 % SOLN 473 ML BOTTLE,42086,CDM,250,RC,436093616,NDC,,,facility,both,473,ML,,56.3,42.22,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Pt Caregiver Training Strategies&Tq 1St 30 Minutes,4209755001,CDM,420,RC,97550,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt Caregiver Training Strategies&Tq Ea Addl 15 Min,4209755101,CDM,420,RC,97551,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt Group Caregiver Training Strategies & Technique,4209755201,CDM,420,RC,97552,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Nonselective Debridement,4209760201,CDM,420,RC,97602,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hb Pt Education And Training For Patient Self-Mgmt,4209896001,CDM,420,RC,98960,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt - E-Stim Unattended,420G028301,CDM,420,RC,G0283,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt - E-Stim Unattended - Pta,420G028302,CDM,420,RC,G0283,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,4.5,ML,,9.84,7.38,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,1,ML,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,10,ML,,16.83,12.62,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,8,ML,,15.6,11.7,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,11.5,ML,,20.2,15.15,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,16,ML,,26,19.5,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,7.5,ML,,15,11.25,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,0.5,ML,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,3,ML,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,4,ML,,10.45,7.84,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,13,ML,,22.2,16.65,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML CONC,42175,CDM,250,RC,54355344,NDC,,,facility,both,12.5,ML,,21.55,16.16,,,,,,,,,,Gross Charge Type: Pharmacy
TRETINOIN 10 MG CAPS,42203,CDM,250,RC,68084007521,NDC,,,facility,both,1,UN,,32.2,24.15,,,,,,,,,,Gross Charge Type: Pharmacy
TRETINOIN 10 MG CAPS,42203,CDM,250,RC,68462079201,NDC,,,facility,both,6,UN,,41.13,30.85,,,,,,,,,,Gross Charge Type: Pharmacy
TRETINOIN 10 MG CAPS,42203,CDM,250,RC,904686704,NDC,,,facility,both,6,UN,,44.73,33.55,,,,,,,,,,Gross Charge Type: Pharmacy
TRETINOIN 10 MG CAPS,42203,CDM,250,RC,68084007521,NDC,,,facility,both,6,UN,,32.14,24.11,,,,,,,,,,Gross Charge Type: Pharmacy
TRETINOIN 10 MG CAPS,42203,CDM,250,RC,904686704,NDC,,,facility,both,5,UN,,45.48,34.11,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND LACTATED RINGERS WITH KCL 20 MEQ/L SOLUTION SOLN,42230,CDM,250,RC,MHS250ML,HCPCS,990711109,NDC,facility,both,250,ML,,7.41,5.56,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND LACTATED RINGERS WITH KCL 20 MEQ/L SOLUTION SOLN,42230,CDM,250,RC,MHS250ML,HCPCS,338081104,NDC,facility,both,250,ML,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 40 MG TABS,42287,CDM,250,RC,69097085805,NDC,,,facility,both,0.5,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 40 MG TABS,42287,CDM,250,RC,69097085805,NDC,,,facility,both,1,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,42291049530,NDC,,,facility,both,1,UN,,39.85,29.89,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,591352530,NDC,,,facility,both,4,UN,,11.82,8.87,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,591267930,NDC,,,facility,both,1,UN,,39.5,29.63,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,42291049530,NDC,,,facility,both,2,UN,,21.75,16.31,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,65162079108,NDC,,,facility,both,4,UN,,13.59,10.19,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,61959000130,NDC,,,facility,both,1,UN,,80.35,60.26,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,65162079108,NDC,,,facility,both,3,UN,,16.73,12.55,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,65162079108,NDC,,,facility,both,1,UN,,41,30.75,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,603188016,NDC,,,facility,both,3,UN,,19.02,14.26,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,63481068701,NDC,,,facility,both,1,UN,,76.8,57.6,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,82347050505,NDC,,,facility,both,1,UN,,42.36,31.77,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,603188016,NDC,,,facility,both,2,UN,,25.3,18.98,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,82347050505,NDC,,,facility,both,2,UN,,23.87,17.9,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,378905593,NDC,,,facility,both,2,UN,,32.35,24.26,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,591267930,NDC,,,facility,both,2,UN,,21.52,16.14,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,61959000130,NDC,,,facility,both,3,UN,,53.48,40.11,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,603188016,NDC,,,facility,both,4,UN,,15.82,11.87,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,65162079108,NDC,,,facility,both,2,UN,,22.92,17.19,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,591352530,NDC,,,facility,both,3,UN,,14.93,11.19,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,61959000130,NDC,,,facility,both,2,UN,,60.65,45.49,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,591352530,NDC,,,facility,both,1,UN,,38.96,29.22,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,82347050505,NDC,,,facility,both,3,UN,,18.02,13.51,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,603188016,NDC,,,facility,both,1,UN,,43.85,32.89,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,378905593,NDC,,,facility,both,1,UN,,51.35,38.51,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,591352530,NDC,,,facility,both,2,UN,,21.02,15.77,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,378905593,NDC,,,facility,both,3,UN,,25.88,19.41,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,591267930,NDC,,,facility,both,3,UN,,15.4,11.55,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % PTCH,42339,CDM,250,RC,591267930,NDC,,,facility,both,4,UN,,12.31,9.23,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSE 4 GM CHEW,42361,CDM,250,RC,56151161011,NDC,,,facility,both,8,UN,,1.14,0.85,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG TABS,42374,CDM,250,RC,67877041933,NDC,,,facility,both,1,UN,,14.8,11.1,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG TABS,42374,CDM,250,RC,904655304,NDC,,,facility,both,0.5,UN,,12.1,9.08,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG TABS,42374,CDM,250,RC,904655304,NDC,,,facility,both,1,UN,,16.15,12.11,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 100 MG/5ML SUSR,42375,CDM,250,RC,MHS1ML,HCPCS,9513601,NDC,facility,both,1,ML,,6.98,5.24,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG TABS,42381,CDM,250,RC,60505025701,NDC,,,facility,both,4,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG TABS,42381,CDM,250,RC,60505025701,NDC,,,facility,both,2,UN,,5.42,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG TABS,42381,CDM,250,RC,60505025701,NDC,,,facility,both,0.5,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG TABS,42381,CDM,250,RC,60505025701,NDC,,,facility,both,3,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG TABS,42381,CDM,250,RC,60505025701,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG SOLR,42414,CDM,250,RC,63323087715,NDC,,,facility,both,1,UN,,209.32,156.99,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG SOLR,42414,CDM,250,RC,13925052201,NDC,,,facility,both,1,UN,,180.45,135.34,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM 0.03 % SOLN 30 ML BOTTLE,42426,CDM,250,RC,54004544,NDC,,,facility,both,30,ML,,59.8,44.85,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM 0.06 % SOLN,42427,CDM,250,RC,MHS1mL,HCPCS,16714052701,NDC,facility,both,1,ML,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM 0.06 % SOLN,42427,CDM,250,RC,MHS1mL,HCPCS,60505082701,NDC,facility,both,1,ML,,3.81,2.86,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM 0.06 % SOLN 15 ML BOTTLE,42427,CDM,250,RC,MHS1mL,HCPCS,54004641,NDC,facility,both,1,ML,,3.99,2.99,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM 0.06 % SOLN 15 ML BOTTLE,42427,CDM,250,RC,MHS1mL,HCPCS,24208039915,NDC,facility,both,1,ML,,4.02,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
FAMCICLOVIR 125 MG TABS,42439,CDM,250,RC,93811756,NDC,,,facility,both,2,UN,,5.42,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
ANASTROZOLE 1 MG TABS,42652,CDM,250,RC,60687011221,NDC,,,facility,both,0.5,UN,,39.75,29.81,,,,,,,,,,Gross Charge Type: Pharmacy
ANASTROZOLE 1 MG TABS,42652,CDM,250,RC,60687011221,NDC,,,facility,both,1,UN,,44.45,33.34,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 1.5 MG CAPS,42667,CDM,250,RC,55111035260,NDC,,,facility,both,1,UN,,8.86,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 1.5 MG CAPS,42667,CDM,250,RC,55111035260,NDC,,,facility,both,3,UN,,3.76,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 3 MG CAPS,42673,CDM,250,RC,55111035360,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 3 MG CAPS,42673,CDM,250,RC,55111035360,NDC,,,facility,both,2,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 3 MG CAPS,42673,CDM,250,RC,72241001203,NDC,,,facility,both,2,UN,,4.05,3.04,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 1 MG TABS,42896,CDM,250,RC,50268035815,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 1 MG TABS,42896,CDM,250,RC,55111032001,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 1 MG TABS,42896,CDM,250,RC,50268035815,NDC,,,facility,both,4,UN,,2.94,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 1 MG TABS,42896,CDM,250,RC,68084078895,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 1 MG TABS,42896,CDM,250,RC,50268035815,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG TABS,42897,CDM,250,RC,68084032601,NDC,,,facility,both,2,UN,,4.8,3.6,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG TABS,42897,CDM,250,RC,68084032601,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG TABS,42897,CDM,250,RC,68084032601,NDC,,,facility,both,0.5,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG TABS,42900,CDM,250,RC,68084032711,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG TABS,42900,CDM,250,RC,16729000301,NDC,,,facility,both,1,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG TABS,42900,CDM,250,RC,55111032201,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG TABS,42900,CDM,250,RC,55111032201,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS,42927,CDM,250,RC,406012501,NDC,,,facility,both,0.5,UN,,5.4,4.05,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS,42927,CDM,250,RC,406012562,NDC,,,facility,both,2,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS,42927,CDM,250,RC,50268040215,NDC,,,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS,42927,CDM,250,RC,406012501,NDC,,,facility,both,1,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS,42927,CDM,250,RC,406012501,NDC,,,facility,both,2,UN,,2.98,2.23,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS,42927,CDM,250,RC,406012562,NDC,,,facility,both,1.5,UN,,3.2,2.4,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS,42927,CDM,250,RC,406012562,NDC,,,facility,both,0.5,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS,42927,CDM,250,RC,406012562,NDC,,,facility,both,1,UN,,6,4.5,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS,42927,CDM,250,RC,50268040215,NDC,,,facility,both,1,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 1,000 ML FLEX CONT",43030,CDM,250,RC,MHS250ML,HCPCS,338001304,NDC,facility,both,250,ML,,12.02,9.02,,,,,,,,,,Gross Charge Type: Pharmacy
"STERILE WATER FOR INJECTION SOLN 2,000 ML BAG",43030,CDM,250,RC,MHS250ML,HCPCS,338001306,NDC,facility,both,250,ML,,28.2,21.15,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE WATER FOR INJECTION SOLN 500 ML FLEX CONT,43030,CDM,250,RC,MHS250ML,HCPCS,264785010,NDC,facility,both,250,ML,,28.67,21.5,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.05 MG/24HR PTWK,43044,CDM,250,RC,378335099,NDC,,,facility,both,1,UN,,49.45,37.09,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.1 MG/24HR PTWK,43046,CDM,250,RC,781710454,NDC,,,facility,both,2,UN,,40.78,30.58,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.1 MG/24HR PTWK,43046,CDM,250,RC,781710454,NDC,,,facility,both,1,UN,,52.3,39.22,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN FLUSH 100 UNITS/ML SOLN,43065,CDM,636,RC,J1642,HCPCS,8290306424,NDC,facility,both,10,UN,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN FLUSH 100 UNITS/ML SOLN,43065,CDM,636,RC,J1642,HCPCS,64253033335,NDC,facility,both,10,UN,,0.57,0.43,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN FLUSH 100 UNITS/ML SOLN 5 ML SYRINGE,43065,CDM,636,RC,J1642,HCPCS,64253033335,NDC,facility,both,10,UN,,0.91,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Ot-Intermittent Compression Pump,4309701601,CDM,430,RC,97016,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot Caregiver Training Strategies&Tq 1St 30 Minutes,4309755001,CDM,430,RC,97550,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot Caregiver Training Strategies&Tq Ea Addl 15 Min,4309755101,CDM,430,RC,97551,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot Group Caregiver Training Strategies & Technique,4309755201,CDM,430,RC,97552,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hb Ot Education And Training For Patient Self-Mgmt,4309896001,CDM,430,RC,98960,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot- E-Stim Unattended,430G028301,CDM,430,RC,G0283,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
PAROXETINE 10 MG TABS,43380,CDM,250,RC,904567661,NDC,,,facility,both,0.5,UN,,1,0.75,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,904567661,NDC,,,facility,both,3,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,904567661,NDC,,,facility,both,2,UN,,5.58,4.18,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,63739088810,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,904567661,NDC,,,facility,both,1.5,UN,,5.15,3.86,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,63739088810,NDC,,,facility,both,2,UN,,5.15,3.86,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,63739088810,NDC,,,facility,both,0.5,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,13107015430,NDC,,,facility,both,1,UN,,7.38,5.53,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,904567661,NDC,,,facility,both,1,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,13107015430,NDC,,,facility,both,4,UN,,2.41,1.81,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,63739088810,NDC,,,facility,both,4,UN,,3.19,2.39,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,904567661,NDC,,,facility,both,4,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS,43380,CDM,250,RC,13107015430,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG TABS 100 EACH BOX,43380,CDM,250,RC,63739088810,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
ANTICOAGULANT CITRATE DEXTROSE FORMULA-A 0.73-2.45-2.2 GM/100 ML SOLN,43679,CDM,250,RC,942064104,NDC,,,facility,both,1000,ML,,36.4,27.3,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,50268052415,NDC,,,facility,both,3,UN,,3.07,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,50268052415,NDC,,,facility,both,3.5,UN,,2.38,1.78,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,3.5,UN,,2.18,1.63,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,1.5,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,50268052415,NDC,,,facility,both,2,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,77333051610,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,50268052415,NDC,,,facility,both,5,UN,,2.06,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,50268052415,NDC,,,facility,both,0.5,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,20,UN,,0.68,0.51,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,2,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,2.5,UN,,2.73,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,50268052415,NDC,,,facility,both,1.5,UN,,4.15,3.11,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,50268052415,NDC,,,facility,both,6.666666667,UN,,1.59,1.19,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,3,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,77333051610,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,1,UN,,6.88,5.16,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,6,UN,,1.58,1.19,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,50268052415,NDC,,,facility,both,1,UN,,7.54,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN 3 MG TABS,43686,CDM,250,RC,20555003601,NDC,,,facility,both,18,UN,,0.72,0.54,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG KIT,43780,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,both,1,ME,,344.69,258.52,,,,,,,,,,Gross Charge Type: Pharmacy
PIMOZIDE 1 MG TABS,43817,CDM,250,RC,49884034701,NDC,,,facility,both,2,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 500 MG SOLR 1 EACH VIAL,43825,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,both,50,ME,,16.44,12.33,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 500MG/50ML SOLR 1 EACH VIAL,43825,CDM,636,RC,J0640,HCPCS,71288016450,NDC,facility,both,50,ME,,26.8,20.1,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 500MG/50ML SOLR 1 EACH VIAL,43825,CDM,636,RC,J0640,HCPCS,63323071100,NDC,facility,both,50,ME,,16.33,12.25,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,55111026281,NDC,,,facility,both,1,UN,,10.83,8.12,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,55111026281,NDC,,,facility,both,2,UN,,7.03,5.27,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,93524565,NDC,,,facility,both,3,UN,,6.07,4.55,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,93524565,NDC,,,facility,both,1.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,55111026281,NDC,,,facility,both,3,UN,,5.67,4.25,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,60505327500,NDC,,,facility,both,4,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,60505327500,NDC,,,facility,both,2,UN,,7.52,5.64,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,93524565,NDC,,,facility,both,0.5,UN,,9.6,7.2,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,55111026281,NDC,,,facility,both,0.5,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,13668008630,NDC,,,facility,both,1,UN,,9.78,7.34,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,60505327500,NDC,,,facility,both,1.5,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,93524565,NDC,,,facility,both,2,UN,,7.52,5.64,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,55111026281,NDC,,,facility,both,1.5,UN,,6.32,4.74,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,60505327500,NDC,,,facility,both,1,UN,,11.49,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,60505327500,NDC,,,facility,both,3,UN,,6.07,4.55,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,60505327503,NDC,,,facility,both,1,UN,,8.87,6.65,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,60505327500,NDC,,,facility,both,0.5,UN,,9.6,7.2,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,55111026281,NDC,,,facility,both,4,UN,,4.94,3.7,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,13668008630,NDC,,,facility,both,2,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,13668008630,NDC,,,facility,both,0.5,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 5 MG TBDP,43837,CDM,250,RC,93524565,NDC,,,facility,both,1,UN,,11.45,8.59,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 10 MG TBDP,43838,CDM,250,RC,13668008830,NDC,,,facility,both,0.5,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 10 MG TBDP,43838,CDM,250,RC,55111026381,NDC,,,facility,both,3,UN,,5.87,4.4,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 10 MG TBDP,43838,CDM,250,RC,55111026381,NDC,,,facility,both,0.5,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 10 MG TBDP,43838,CDM,250,RC,55111026381,NDC,,,facility,both,1.5,UN,,6.48,4.86,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 10 MG TBDP,43838,CDM,250,RC,55111026381,NDC,,,facility,both,1,UN,,11.02,8.27,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 10 MG TBDP,43838,CDM,250,RC,13668008830,NDC,,,facility,both,2,UN,,6.58,4.93,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 10 MG TBDP,43838,CDM,250,RC,13668008830,NDC,,,facility,both,1,UN,,10.5,7.88,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 10 MG TBDP,43838,CDM,250,RC,93524619,NDC,,,facility,both,1,UN,,13.2,9.9,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE TABLET DISPERSIBLE 10 MG TBDP,43838,CDM,250,RC,55111026381,NDC,,,facility,both,2,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
COLESEVELAM 625 MG TABS,43846,CDM,250,RC,67877050651,NDC,,,facility,both,3,UN,,4.43,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.01 % SOLN 5 ML BOTTLE,43888,CDM,250,RC,MHS1ML,HCPCS,60505081500,NDC,facility,both,1,ML,,36.11,27.08,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG TABS,43961,CDM,250,RC,16714017601,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG TABS,43961,CDM,250,RC,50268009612,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG TABS,43961,CDM,250,RC,904629304,NDC,,,facility,both,0.5,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG TABS,43961,CDM,250,RC,904629304,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
Hc St- Laryngoscopy Telescopic,4403157901,CDM,440,RC,31579,HCPCS,,,facility,both,,,,872,654,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
SEVELAMER 800 MG TABS,44042,CDM,250,RC,70748017326,NDC,,,facility,both,3,UN,,10.63,7.97,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER 800 MG TABS,44042,CDM,250,RC,68462044718,NDC,,,facility,both,1,UN,,16.7,12.52,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER 800 MG TABS,44042,CDM,250,RC,68462044718,NDC,,,facility,both,3,UN,,10.63,7.97,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER 800 MG TABS,44042,CDM,250,RC,70748017326,NDC,,,facility,both,4,UN,,9.75,7.31,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER 800 MG TABS,44042,CDM,250,RC,68462044718,NDC,,,facility,both,2,UN,,12.22,9.17,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER 800 MG TABS,44042,CDM,250,RC,60687044911,NDC,,,facility,both,2,UN,,17,12.75,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER 800 MG TABS,44042,CDM,250,RC,70748017326,NDC,,,facility,both,1,UN,,16.7,12.52,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER 800 MG TABS,44042,CDM,250,RC,70748017326,NDC,,,facility,both,2,UN,,12.22,9.17,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER 800 MG TABS,44042,CDM,250,RC,60687044911,NDC,,,facility,both,1,UN,,21.8,16.35,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER 800 MG TABS,44042,CDM,250,RC,60687044911,NDC,,,facility,both,3,UN,,15.25,11.44,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG TBCR,44080,CDM,250,RC,62037072501,NDC,,,facility,both,1,UN,,12.95,9.71,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG TBCR,44080,CDM,250,RC,62175031037,NDC,,,facility,both,2,UN,,10.6,7.95,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG TBCR,44080,CDM,250,RC,62175031037,NDC,,,facility,both,1,UN,,13.2,9.9,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 36 MG TBCR,44081,CDM,250,RC,406013601,NDC,,,facility,both,1,UN,,12.7,9.52,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 36 MG TBCR,44081,CDM,250,RC,406013601,NDC,,,facility,both,2,UN,,10.08,7.56,,,,,,,,,,Gross Charge Type: Pharmacy
Hc St-Electrical Stimulation-Manual Ea 15Mi,4409703201,CDM,440,RC,97032,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St-Manual Therapy Techniques-Ea 15 Min,4409714001,CDM,440,RC,97140,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St Caregiver Training Strategies&Tq 1St 30 Minutes,4409755001,CDM,440,RC,97550,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St Caregiver Training Strategies&Tq Ea Addl 15 Min,4409755101,CDM,440,RC,97551,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St Group Caregiver Training Strategies & Technique,4409755201,CDM,440,RC,97552,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 SUSP 10 ML BOTTLE,44116,CDM,250,RC,MHS1ML,HCPCS,61314064511,NDC,facility,both,1,ML,,14.48,10.86,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2ML SUSP,44238,CDM,250,RC,487960101,NDC,,,facility,both,2,ML,,26.85,20.14,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2ML SUSP,44238,CDM,250,RC,186198804,NDC,,,facility,both,2,ML,,28.2,21.15,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,16714001930,NDC,,,facility,both,4,ML,,9.62,7.22,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,186198904,NDC,,,facility,both,0.5,ML,,30.75,23.06,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,16714001930,NDC,,,facility,both,2,ML,,15.75,11.81,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,186198904,NDC,,,facility,both,1,ML,,30.75,23.06,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,487970101,NDC,,,facility,both,1,ML,,18.25,13.69,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,487970101,NDC,,,facility,both,2,ML,,26.99,20.24,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,16714001930,NDC,,,facility,both,0.5,ML,,12.85,9.64,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,186198904,NDC,,,facility,both,2,ML,,30.75,23.06,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,69097031987,NDC,,,facility,both,2,ML,,18.15,13.61,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2ML SUSP,44239,CDM,250,RC,487970101,NDC,,,facility,both,4,ML,,21.02,15.76,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 25 MG CAPS,44295,CDM,636,RC,J7515,HCPCS,93901865,NDC,facility,both,25,ME,,4.63,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 25 MG CAPS,44295,CDM,636,RC,J7515,HCPCS,78024615,NDC,facility,both,25,ME,,7.26,5.45,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 25 MG CAPS,44295,CDM,636,RC,J7515,HCPCS,51862045847,NDC,facility,both,25,ME,,4.18,3.14,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG CAPS,44296,CDM,636,RC,J7502,HCPCS,74310932,NDC,facility,both,100,ME,,15,11.25,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG CAPS,44296,CDM,636,RC,J7502,HCPCS,60505463203,NDC,facility,both,100,ME,,16.5,12.38,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG CAPS,44296,CDM,636,RC,J7502,HCPCS,51862046047,NDC,facility,both,100,ME,,14.1,10.58,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE/SODIUM CHONDROITIN 0.55-0.5 ML KIT,44323,CDM,250,RC,8065183150,NDC,,,facility,both,1.05,ML,,163.8,122.85,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE/SODIUM CHONDROITIN 0.55-0.5 ML KIT,44323,CDM,250,RC,8065183150,NDC,,,facility,both,2.1,ML,,147.98,110.98,,,,,,,,,,Gross Charge Type: Pharmacy
ARGATROBAN 250 MG/2.5ML SOLN 2.5 ML VIAL,44354,CDM,636,RC,J0883,HCPCS,409114001,NDC,facility,both,1,ME,,3.54,2.65,,,,,,,,,,Gross Charge Type: Pharmacy
ARGATROBAN 250 MG/2.5ML SOLN 2.5 ML VIAL,44354,CDM,636,RC,J0883,HCPCS,143967401,NDC,facility,both,1,ME,,4.79,3.59,,,,,,,,,,Gross Charge Type: Pharmacy
ARGATROBAN 250 MG/2.5ML SOLN 2.5 ML VIAL,44354,CDM,636,RC,J0883,HCPCS,42023018201,NDC,facility,both,1,ME,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 750 MG TABS,44378,CDM,250,RC,31722072320,NDC,,,facility,both,1,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TB24,44424,CDM,250,RC,62756014201,NDC,,,facility,both,2,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TB24,44424,CDM,250,RC,70010049101,NDC,,,facility,both,4,UN,,1.8,1.35,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TB24,44424,CDM,250,RC,62756014201,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TB24,44424,CDM,250,RC,70010049101,NDC,,,facility,both,1.5,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TB24,44424,CDM,250,RC,50268055015,NDC,,,facility,both,2,UN,,4.82,3.62,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TB24,44424,CDM,250,RC,62756014201,NDC,,,facility,both,4,UN,,2.05,1.54,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TB24,44424,CDM,250,RC,70010049101,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 500 MG TB24,44424,CDM,250,RC,70010049101,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 1 MG/ML SOLN 10 ML VIAL,44506,CDM,636,RC,J9017,HCPCS,63323063703,NDC,facility,both,1,ME,,199.35,149.51,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAPS,4454,CDM,250,RC,51079014120,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAPS,4454,CDM,250,RC,555015902,NDC,,,facility,both,1,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAPS,4454,CDM,250,RC,51079014120,NDC,,,facility,both,2,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAPS,4454,CDM,250,RC,555015902,NDC,,,facility,both,2,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 5 MG CAPS,4455,CDM,250,RC,51079037420,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 20 MG/ML SOLN,44566,CDM,636,RC,J1756,HCPCS,517234010,NDC,facility,both,1,ME,,1.1,0.82,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 20 MG/ML SOLN 5 ML VIAL,44566,CDM,636,RC,J1756,HCPCS,517234010,NDC,facility,both,1,ME,,1.04,0.78,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 20 MG TABS,44612,CDM,250,RC,68382047130,NDC,,,facility,both,0.5,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 20 MG TABS,44612,CDM,250,RC,68382047130,NDC,,,facility,both,4,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 20 MG TABS,44612,CDM,250,RC,68382047130,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 15 MG TABS,44625,CDM,250,RC,527150437,NDC,,,facility,both,2,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE 4 % SOLN 118 ML BOTTLE,4464,CDM,250,RC,234057504,NDC,,,facility,both,118,ML,,39.95,29.96,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE 4 % SOLN 118 ML BOTTLE,4464,CDM,250,RC,234057504,NDC,,,facility,both,1,ML,,20.65,15.49,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE 4 % SOLN 118 ML BOTTLE,4464,CDM,250,RC,116106104,NDC,,,facility,both,1,ML,,20.7,15.52,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,0.6667,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,3,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,2.6667,UN,,3.18,2.39,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,1.6667,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,2.3333,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,1,UN,,6.89,5.17,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,4,UN,,2.61,1.96,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,2.5,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,0.5,UN,,6.19,4.64,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,0.8333,UN,,1.7,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG TABS,44707,CDM,250,RC,904664261,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG CAPS,44723,CDM,250,RC,54007928,NDC,,,facility,both,2,UN,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG CAPS,44723,CDM,250,RC,54007928,NDC,,,facility,both,4,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG CAPS,44723,CDM,250,RC,54007928,NDC,,,facility,both,3,UN,,3.82,2.86,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE 15 MG/5ML SOLN,44727,CDM,636,RC,J7510,HCPCS,60432021208,NDC,facility,both,5,ME,,1.37,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML OR SOLN,44727,CDM,121075908,NDC,,,,,facility,both,5,ML,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SOLN,44765,CDM,636,RC,J1800,HCPCS,63323060401,NDC,facility,both,1,ME,,36.15,27.11,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 1 MG/ML SOLN,44765,CDM,636,RC,J1800,HCPCS,143987210,NDC,facility,both,1,ME,,39,29.25,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 240 MG CP24,44780,CDM,250,RC,60505001606,NDC,,,facility,both,1,UN,,9.65,7.24,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR,44871,CDM,636,RC,C9113,HCPCS,781323295,NDC,facility,both,40,ME,,51.86,38.89,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR,44871,CDM,636,RC,C9113,HCPCS,62756012944,NDC,facility,both,40,ME,,45.31,33.99,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR,44871,CDM,636,RC,C9113,HCPCS,72603012810,NDC,facility,both,40,ME,,38.38,28.79,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR,44871,CDM,636,RC,C9113,HCPCS,8092355,NDC,facility,both,40,ME,,60.3,45.22,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR,44871,CDM,636,RC,C9113,HCPCS,71288060010,NDC,facility,both,40,ME,,45.88,34.41,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR,44871,CDM,636,RC,C9113,HCPCS,143928410,NDC,facility,both,40,ME,,44.12,33.09,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR,44871,CDM,636,RC,C9113,HCPCS,62756012940,NDC,facility,both,40,ME,,45.48,34.11,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR,44871,CDM,636,RC,C9113,HCPCS,55150020210,NDC,facility,both,40,ME,,38.02,28.52,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR,44871,CDM,636,RC,C9113,HCPCS,72572055001,NDC,facility,both,40,ME,,46.16,34.62,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR 1 EACH VIAL,44871,CDM,636,RC,C9113,HCPCS,62756012940,NDC,facility,both,40,ME,,32.73,24.55,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR 1 EACH VIAL,44871,CDM,636,RC,C9113,HCPCS,71288060010,NDC,facility,both,40,ME,,32.68,24.51,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR 1 EACH VIAL,44871,CDM,636,RC,C9113,HCPCS,72572055001,NDC,facility,both,40,ME,,33.37,25.02,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR 1 EACH VIAL,44871,CDM,636,RC,C9113,HCPCS,781323295,NDC,facility,both,40,ME,,34.7,26.03,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR 1 EACH VIAL,44871,CDM,636,RC,C9113,HCPCS,55150020210,NDC,facility,both,40,ME,,25.63,19.23,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR 1 EACH VIAL,44871,CDM,636,RC,C9113,HCPCS,62756012944,NDC,facility,both,40,ME,,32.55,24.41,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR 1 EACH VIAL,44871,CDM,636,RC,C9113,HCPCS,72603012810,NDC,facility,both,40,ME,,26.44,19.83,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR 1 EACH VIAL,44871,CDM,636,RC,C9113,HCPCS,8092355,NDC,facility,both,40,ME,,37.79,28.34,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE SOLR 1 EACH VIAL,44871,CDM,636,RC,C9113,HCPCS,143928410,NDC,facility,both,40,ME,,32.47,24.36,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% AND 0.22% NACL WITH KCL 20 MEQ/L SOLUTION 20-5-0.2 MEQ/L-%-% SOLN,44876,CDM,250,RC,MHS1ML,HCPCS,338066304,NDC,facility,both,1,ML,,0.02,0.01,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 120 MG CP24,44893,CDM,250,RC,60687019501,NDC,,,facility,both,4,UN,,2.51,1.88,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 120 MG CP24,44893,CDM,250,RC,60687019501,NDC,,,facility,both,3,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 120 MG CP24,44893,CDM,250,RC,60687019501,NDC,,,facility,both,1,UN,,7.72,5.79,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 120 MG CP24,44893,CDM,250,RC,60687019501,NDC,,,facility,both,2,UN,,4.42,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 180 MG CP24,44895,CDM,250,RC,60687020601,NDC,,,facility,both,2,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 180 MG CP24,44895,CDM,250,RC,60687020601,NDC,,,facility,both,2.6667,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 180 MG CP24,44895,CDM,250,RC,60687020601,NDC,,,facility,both,1,UN,,7.36,5.52,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 240 MG CP24,44896,CDM,250,RC,47335067181,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 240 MG CP24,44896,CDM,250,RC,68682036990,NDC,,,facility,both,1,UN,,10,7.5,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 300 MG CP24,44899,CDM,250,RC,10370083211,NDC,,,facility,both,1,UN,,11.5,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN LIQD 177 ML BOTTLE,44926,CDM,250,RC,395103196,NDC,,,facility,both,60,ML,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN LIQD 177 ML BOTTLE,44926,CDM,250,RC,395103196,NDC,,,facility,both,100,ML,,11.3,8.48,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE,44953,CDM,250,RC,MHS1GM,HCPCS,16714049601,NDC,facility,both,1,GM,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG CP24,44963,CDM,250,RC,43975032203,NDC,,,facility,both,1,UN,,11.25,8.44,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 4 MG CP24,44964,CDM,250,RC,59762004802,NDC,,,facility,both,1,UN,,13,9.75,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 4 MG CP24,44964,CDM,250,RC,59762004801,NDC,,,facility,both,1,UN,,12.95,9.71,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.1 % OINT 30 G TUBE,44973,CDM,250,RC,MHS1GM,HCPCS,45802070000,NDC,facility,both,1,GM,,6.32,4.74,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE B 5000 UNITS/ML SOLN,44979,CDM,636,RC,J0587,HCPCS,10454071110,NDC,facility,both,100,UN,,22.66,17,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE B 5000 UNITS/ML SOLN,44979,CDM,636,RC,J0587,HCPCS,10454071010,NDC,facility,both,100,UN,,22.88,17.16,,,,,,,,,,Gross Charge Type: Pharmacy
Hc P1 Pov Trauma Without Critical Care,4500000001,CDM,450,RC,,,,,facility,both,,,,6232,4674,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P1 Pov Trauma Without Critical Care,4500000001,CDM,450,RC,,,,,facility,both,,,,6232,4674,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P2 Pov Trauma Without Critical Care,4500000002,CDM,450,RC,,,,,facility,both,,,,5665,4248.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P2 Pov Trauma Without Critical Care,4500000002,CDM,450,RC,,,,,facility,both,,,,5665,4248.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P3 Pov Trauma Without Critical Care,4500000003,CDM,450,RC,,,,,facility,both,,,,4950,3712.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P3 Pov Trauma Without Critical Care,4500000003,CDM,450,RC,,,,,facility,both,,,,4950,3712.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incision And Drainage Pilonidal Cyst Complicated,4501008101,CDM,450,RC,10081,HCPCS,,,facility,both,,,,2513,1884.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Incision And Drainage, Complex, Postoperative Wound Infection",4501018001,CDM,450,RC,10180,HCPCS,,,facility,both,,,,3941,2955.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Debride Skin At Fx Site,4501101001,CDM,450,RC,11010,HCPCS,,,facility,both,,,,780,585,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Dbrdmt Fx And/Dislc Subq T/M/F Bone,4501101201,CDM,450,RC,11012,HCPCS,,,facility,both,,,,4743,3557.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or External Genitalia, 12.6 Cm To 20.0 Cm",4501204501,CDM,450,RC,12045,HCPCS,,,facility,both,,,,2094,1570.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Complex Repair Trunk 2.6-7.5Cm,4501310101,CDM,450,RC,13101,HCPCS,,,facility,both,,,,1380,1035,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Complex Repair Trunk Add-On 5C,4501310201,CDM,450,RC,13102,HCPCS,,,facility,both,,,,690,517.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Explore Wound Chest,4502010101,CDM,450,RC,20101,HCPCS,,,facility,both,,,,4422,3316.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Monitoring Of Interstitial Fluid Pressure In Detection Of Muscle Compartment Syndrome,4502095001,CDM,450,RC,20950,HCPCS,,,facility,both,,,,3171,2378.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Cltx Prox Humrl Fx W/Manj W/Wo Skeletal Tracj,4502360501,CDM,450,RC,23605,HCPCS,,,facility,both,,,,3644,2733,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Treat Humerus Fx Cond W/Manip,4502457701,CDM,450,RC,24577,HCPCS,,,facility,both,,,,1835,1376.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Treat Elbow Disloc W/Anes,4502460501,CDM,450,RC,24605,HCPCS,,,facility,both,,,,3410,2557.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Treat Fx Of Radius W/O Manip,4502550001,CDM,450,RC,25500,HCPCS,,,facility,both,,,,472,354,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Treat Fx Of Radius W/O Manip,4502550001,CDM,450,RC,25500,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Fx Radius & Ulna W/O Man,4502556001,CDM,450,RC,25560,HCPCS,,,facility,both,,,,417,312.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Cltx Trans-Scaphoprilunar Typ Fx Dislc W/Manj,4502568001,CDM,450,RC,25680,HCPCS,,,facility,both,,,,1124,843,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Closed Tx Metacarpophalangeal Dislc W/Manip W/O Anes,4502670001,CDM,450,RC,26700,HCPCS,,,facility,both,,,,977,732.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Closed Tx Metacarpophalangeal Dislc W/Manip W/O Anes,4502670001,CDM,450,RC,26700,HCPCS,,,facility,both,,,,977,732.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Joint Capsule Repair Finger,4502698901,CDM,450,RC,26989,HCPCS,,,facility,both,,,,1536,1152,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Clsd Rx Hip Arthroplasty W/Ans,4502726601,CDM,450,RC,27266,HCPCS,,,facility,both,,,,3664,2748,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Closed Tx Fem Shft Fx, W/Manip, W/Wo Skin/Skeletal Traction",4502750201,CDM,450,RC,27502,HCPCS,,,facility,both,,,,2734,2050.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Closed Tx Fem Shft Fx, W/Manip, W/Wo Skin/Skeletal Traction",4502750201,CDM,450,RC,27502,HCPCS,,,facility,both,,,,2734,2050.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Treatment Knee Fracture,4502753201,CDM,450,RC,27532,HCPCS,,,facility,both,,,,3898,2923.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Closed Tx Knee Dislocation W/O Anesthesia,4502755001,CDM,450,RC,27550,HCPCS,,,facility,both,,,,1124,843,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Closed Treatment Of Knee Dislocation: Requiring Anesthesia,4502755201,CDM,450,RC,27552,HCPCS,,,facility,both,,,,5668,4251,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Closed Treatment Of Patellar Dislocation; Requiring Anesthesia,4502756201,CDM,450,RC,27562,HCPCS,,,facility,both,,,,2866,2149.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Clsd Tx Posterior Fx W/Manip,4502776801,CDM,450,RC,27768,HCPCS,,,facility,both,,,,1792,1344,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Closed Tx Bimalleolar Ankle Fracture W/O Manip,4502780801,CDM,450,RC,27808,HCPCS,,,facility,both,,,,951,713.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Treat Lower Leg Fx W/O Manip,4502782401,CDM,450,RC,27824,HCPCS,,,facility,both,,,,589,441.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Leg/Ankle Surgery Procedure,4502789901,CDM,450,RC,27899,HCPCS,,,facility,both,,,,2079,1559.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Removal Foreign Body Foot Subcutaneous,4502819001,CDM,450,RC,28190,HCPCS,,,facility,both,,,,1276,957,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Foreign Body Foot Subcutaneous,4502819001,CDM,450,RC,28190,HCPCS,,,facility,both,,,,1276,957,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Removal Foreign Body Foot Subcutaneous,4502819001,CDM,450,RC,28190,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Rem Of Foot Fb Deep,4502819201,CDM,450,RC,28192,HCPCS,,,facility,both,,,,2961,2220.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Repair Of Foot Tendon,4502820801,CDM,450,RC,28208,HCPCS,,,facility,both,,,,3687,2765.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Tx Of Heel Fx W/Manip,4502840501,CDM,450,RC,28405,HCPCS,,,facility,both,,,,1287,965.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Unlisted Procedure, Foot Or Toes",4502889901,CDM,450,RC,28899,HCPCS,,,facility,both,,,,5006,3754.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Application Short Arm Splint Dynamic,4502912601,CDM,450,RC,29126,HCPCS,,,facility,both,,,,531,398.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Drainage Abscess/Hematoma Nasal Septum,4503002001,CDM,450,RC,30020,HCPCS,,,facility,both,,,,2113,1584.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Repeat Control Of Nosebleed,4503090601,CDM,450,RC,30906,HCPCS,,,facility,both,,,,373,279.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Diagnostic Laryngoscopy,4503150501,CDM,450,RC,31505,HCPCS,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Thoracotomy With Exploration,4503210001,CDM,450,RC,32100,HCPCS,,,facility,both,,,,4600,3450,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thoracotomy W/Cardiac Massage,4503216001,CDM,450,RC,32160,HCPCS,,,facility,both,,,,4000,3000,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Insertion Of Needle Into Vein (Younger Than 3 Years),4503640601,CDM,450,RC,36406,HCPCS,,,facility,both,,,,213,159.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc  Insertion Of Non-Tunneled Centrally Inserted Central Venous Catheter; Younger Than 5 Years Of Ag,4503655501,CDM,450,RC,36555,HCPCS,,,facility,both,,,,3985,2988.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Vascular Surgery Procedure,4503779901,CDM,450,RC,37799,HCPCS,,,facility,both,,,,3023,2267.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
CHLORPHENIRAMINE 4 MG TABS,4504,CDM,250,RC,904001261,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Rpr Lip Full Thickness Half/< Vertical Height,4504065201,CDM,450,RC,40652,HCPCS,,,facility,both,,,,1619,1214.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Repair Of Lac 2.5Cm Or Less,4504125101,CDM,450,RC,41251,HCPCS,,,facility,both,,,,667,500.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Esophagogastroduodenoscopy,Flexible,Transoral; With Biopsy, Single Or Multiple",4504323901,CDM,450,RC,43239,HCPCS,,,facility,both,,,,2757,2067.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Dilation Esoph Unguided Sound/Bougie 1/Mult Pass,4504345001,CDM,450,RC,43450,HCPCS,,,facility,both,,,,3798,2848.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Unlisted; Replace Peg Tube With Foley Cath,4504999901,CDM,450,RC,49999,HCPCS,,,facility,both,,,,1101,825.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Incise & Drain Bladder,4505104001,CDM,450,RC,51040,HCPCS,,,facility,both,,,,6146,4609.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
CLINDAMYCIN-BENZOYL PEROXIDE 1-5 % GEL 25 G JAR,45052,CDM,250,RC,51672138102,NDC,,,facility,both,25,GR,,103.05,77.29,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Prepurial Stretching,4505445001,CDM,450,RC,54450,HCPCS,,,facility,both,,,,690,517.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Incision And Drainage Epididymis Testis And Or Scrotal Space,4505470001,CDM,450,RC,54700,HCPCS,,,facility,both,,,,7544,5658,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incision And Drainage Epididymis Testis And Or Scrotal Space,4505470001,CDM,450,RC,54700,HCPCS,,,facility,both,,,,7544,5658,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Puncture Aspiration Of Hydrocele, Tunica Vaginalis, With Or Without Injection Of Medication",4505500001,CDM,450,RC,55000,HCPCS,,,facility,both,,,,1150,862.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Vaginal Delivery Only (W/Or W/O Episio And Or Forceps),4505940901,CDM,450,RC,59409,HCPCS,,,facility,both,,,,8129,6096.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Injection(S), Anesthetic Agent(S) And/Or Steroid; Brachial Plexus, Including Imaging Guidance, When",4506441501,CDM,450,RC,64415,HCPCS,,,facility,both,,,,1929,1446.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Sphenopalatine Nerve Block,4506499901,CDM,450,RC,64999,HCPCS,,,facility,both,,,,802,601.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
MIRTAZAPINE 15 MG TBDP,45065,CDM,250,RC,52010630,NDC,,,facility,both,2,UN,,11.8,8.85,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TBDP,45065,CDM,250,RC,52010630,NDC,,,facility,both,3,UN,,10.22,7.66,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TBDP,45065,CDM,250,RC,65862002106,NDC,,,facility,both,3,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TBDP,45065,CDM,250,RC,65862002106,NDC,,,facility,both,1.5,UN,,5.18,3.88,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TBDP,45065,CDM,250,RC,65862002106,NDC,,,facility,both,0.5,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TBDP,45065,CDM,250,RC,52010630,NDC,,,facility,both,0.5,UN,,12.2,9.15,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TBDP,45065,CDM,250,RC,65862002106,NDC,,,facility,both,2,UN,,5.62,4.22,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TBDP,45065,CDM,250,RC,52010630,NDC,,,facility,both,1,UN,,16.25,12.19,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG TBDP,45065,CDM,250,RC,65862002106,NDC,,,facility,both,1,UN,,9.45,7.09,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Canthotomy/Incision Eyelid Fld,4506771501,CDM,450,RC,67715,HCPCS,,,facility,both,,,,3649,2736.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Dilate Tear Duct W/Wo Irrig,4506880101,CDM,450,RC,68801,HCPCS,,,facility,both,,,,751,563.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Osteopathic Manipulative Treatment (Omt); 1-2 Body Regions Involved,4509892501,CDM,450,RC,98925,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Moderate Sedation Other Phys/Qhp Each Addl 15 Mins,4509915701,CDM,450,RC,99157,HCPCS,,,facility,both,,,,205,153.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Ed Critical Care First Hour,4509929101,CDM,450,RC,99291,HCPCS,,,facility,both,,,,1860,1395,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ed Critical Care First Hour,4509929101,CDM,450,RC,99291,HCPCS,,,facility,both,,,,2132,1599,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Critical Care Ea Addl 30 Min,4509929201,CDM,450,RC,99292,HCPCS,,,facility,both,,,,2132,1599,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P1 Pov Trauma With Critical Care,450G039001,CDM,450,RC,G0390,HCPCS,,,facility,both,,,,7882,5911.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P1 Pov Trauma With Critical Care,450G039001,CDM,450,RC,G0390,HCPCS,,,facility,both,,,,7882,5911.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P2 Pov Trauma With Critical Care,450G039002,CDM,450,RC,G0390,HCPCS,,,facility,both,,,,7315,5486.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P2 Pov Trauma With Critical Care,450G039002,CDM,450,RC,G0390,HCPCS,,,facility,both,,,,7315,5486.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P3 Pov Trauma With Critical Care,450G039003,CDM,450,RC,G0390,HCPCS,,,facility,both,,,,6600,4950,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P3 Pov Trauma With Critical Care,450G039003,CDM,450,RC,G0390,HCPCS,,,facility,both,,,,6600,4950,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Alcohol And/Or Substance (Other Than Tobacco) Misuse Structured Assessment (E.G., Audit, Dast), A",450G039601,CDM,450,RC,G0396,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Alcohol And/Or Substance (Other Than Tobacco) Misuse Structured Assessment (E.G., Audit, Dast), A",450G039601,CDM,450,RC,G0396,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Alcohol And/Or Substance (Other Than Tobacco) Misuse Structured Assessment (E.G., Audit, Dast), A",450G039701,CDM,450,RC,G0397,HCPCS,,,facility,both,,,,217,162.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Alcohol And/Or Substance (Other Than Tobacco) Misuse Structured Assessment (E.G., Audit, Dast), A",450G039701,CDM,450,RC,G0397,HCPCS,,,facility,both,,,,217,162.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Alcohol And/Or Substance (Other Than Tobacco) Misuse Structured Assessment (E.G., Audit, Dast), A",450G201101,CDM,450,RC,G2011,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Alcohol And/Or Substance (Other Than Tobacco) Misuse Structured Assessment (E.G., Audit, Dast), A",450G201101,CDM,450,RC,G2011,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
CHLORPROMAZINE 10 MG TABS,4516,CDM,250,RC,832601700,NDC,,,facility,both,1,UN,,13.25,9.94,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG TABS,4519,CDM,250,RC,69238105601,NDC,,,facility,both,1,UN,,9.28,6.96,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG TABS,4519,CDM,250,RC,16714004801,NDC,,,facility,both,1,UN,,12.05,9.04,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG TABS,4519,CDM,250,RC,69238105601,NDC,,,facility,both,2,UN,,5.68,4.26,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG TABS,4519,CDM,250,RC,50268016315,NDC,,,facility,both,1,UN,,18.65,13.99,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG TABS,4519,CDM,250,RC,50268016315,NDC,,,facility,both,2,UN,,14.05,10.54,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,69238105801,NDC,,,facility,both,2,UN,,10.45,7.84,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,904713161,NDC,,,facility,both,1,UN,,20.15,15.11,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,904713161,NDC,,,facility,both,0.5,UN,,14.35,10.76,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,69238105801,NDC,,,facility,both,3,UN,,8.88,6.66,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,904713161,NDC,,,facility,both,4,UN,,12.81,9.61,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,904713161,NDC,,,facility,both,2,UN,,15.48,11.61,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,69238105801,NDC,,,facility,both,4,UN,,8.08,6.06,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,904713161,NDC,,,facility,both,3,UN,,13.7,10.28,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,904713161,NDC,,,facility,both,1.5,UN,,12.78,9.58,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,69238105801,NDC,,,facility,both,1,UN,,10.75,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,69238105801,NDC,,,facility,both,6,UN,,7.19,5.39,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 50 MG TABS,4520,CDM,250,RC,69238105801,NDC,,,facility,both,1.5,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE 25 MG TABS,4525,CDM,250,RC,51079005820,NDC,,,facility,both,1,UN,,11.75,8.81,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE 25 MG TABS,4525,CDM,250,RC,904690004,NDC,,,facility,both,0.5,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE 25 MG TABS,4525,CDM,250,RC,904690004,NDC,,,facility,both,2,UN,,7.88,5.91,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE 25 MG TABS,4525,CDM,250,RC,51079005820,NDC,,,facility,both,2,UN,,7.72,5.79,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE 25 MG TABS,4525,CDM,250,RC,51079005820,NDC,,,facility,both,0.5,UN,,9.75,7.31,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE 25 MG TABS,4525,CDM,250,RC,904690004,NDC,,,facility,both,1,UN,,11.9,8.92,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAPS,45336,CDM,250,RC,904626945,NDC,,,facility,both,4,UN,,6.06,4.55,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAPS,45336,CDM,250,RC,904626945,NDC,,,facility,both,1,UN,,11.28,8.46,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAPS,45336,CDM,250,RC,904626945,NDC,,,facility,both,3,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAPS,45336,CDM,250,RC,904626945,NDC,,,facility,both,2,UN,,8.3,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAPS,45336,CDM,250,RC,65862070260,NDC,,,facility,both,1,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAPS 80 EACH BOX,45336,CDM,250,RC,904626945,NDC,,,facility,both,1,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAPS,45337,CDM,250,RC,68084010409,NDC,,,facility,both,1,UN,,13.5,10.12,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAPS,45337,CDM,250,RC,68084010409,NDC,,,facility,both,4,UN,,6.98,5.23,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAPS,45337,CDM,250,RC,68084010409,NDC,,,facility,both,2,UN,,9.28,6.96,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAPS,45337,CDM,250,RC,68084010409,NDC,,,facility,both,3,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAPS 1 EACH BLISTER,45337,CDM,250,RC,68084010409,NDC,,,facility,both,1,UN,,13.5,10.12,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 80 MG CAPS,45339,CDM,250,RC,68084010609,NDC,,,facility,both,1,UN,,12.57,9.43,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 80 MG CAPS,45339,CDM,250,RC,68084010609,NDC,,,facility,both,1.5,UN,,8.05,6.04,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 80 MG CAPS,45339,CDM,250,RC,68084010609,NDC,,,facility,both,2,UN,,9.28,6.96,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 80 MG CAPS,45339,CDM,250,RC,68084010609,NDC,,,facility,both,0.75,UN,,12.1,9.08,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL IN NS 10 MG/ML SOLN,45364,CDM,636,RC,J1805,HCPCS,25021030884,NDC,facility,both,10,ME,,1.66,1.25,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL IN NS 10 MG/ML SOLN,45364,CDM,636,RC,J1805,HCPCS,10019005561,NDC,facility,both,10,ME,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL IN NS 10 MG/ML SOLN,45364,CDM,636,RC,J1805,HCPCS,55150042001,NDC,facility,both,10,ME,,1.65,1.24,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL IN NS 10 MG/ML SOLN,45364,CDM,636,RC,J1805,HCPCS,55150042010,NDC,facility,both,10,ME,,1.3,0.97,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL IN NS 10 MG/ML SOLN,45364,CDM,636,RC,J1805,HCPCS,67457065725,NDC,facility,both,10,ME,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632206,NDC,,,facility,both,4,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,51079016920,NDC,,,facility,both,1.5,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,51079016920,NDC,,,facility,both,4,UN,,2.89,2.17,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,50742061501,NDC,,,facility,both,4,UN,,2.46,1.85,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,50742061501,NDC,,,facility,both,0.5,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632261,NDC,,,facility,both,1.5,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632206,NDC,,,facility,both,1,UN,,8.27,6.2,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632261,NDC,,,facility,both,1,UN,,8.43,6.32,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632206,NDC,,,facility,both,0.5,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,51079016920,NDC,,,facility,both,2,UN,,4.82,3.62,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632206,NDC,,,facility,both,3,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,51079016920,NDC,,,facility,both,0.5,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632206,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632261,NDC,,,facility,both,3,UN,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,50742061501,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,50742061501,NDC,,,facility,both,1,UN,,6.84,5.13,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632261,NDC,,,facility,both,4,UN,,3.06,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,51079016920,NDC,,,facility,both,1,UN,,7.59,5.69,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,51079016920,NDC,,,facility,both,3,UN,,3.53,2.65,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632261,NDC,,,facility,both,2,UN,,5,3.75,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632261,NDC,,,facility,both,0.5,UN,,7.7,5.78,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 25 MG TB24,45415,CDM,250,RC,904632261,NDC,,,facility,both,0.25,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 180 MG CAPS,45558,CDM,250,RC,67627418,NDC,,,facility,both,1,UN,,7.75,5.81,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNITS/ML SOLN,45566,CDM,637,RC,J1815,HCPCS,88222033,NDC,facility,both,5,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNITS/ML SOLN,45566,CDM,636,RC,J1815,HCPCS,88222033,NDC,facility,both,5,UN,,8.11,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE 4 MG TABS,45568,CDM,250,RC,57237004960,NDC,,,facility,both,4,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE 4 MG TABS,45568,CDM,250,RC,57237004960,NDC,,,facility,both,2,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE 4 MG TABS,45568,CDM,250,RC,57237004960,NDC,,,facility,both,1,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 450 MG TABS,45754,CDM,250,RC,65862075360,NDC,,,facility,both,2,UN,,11.32,8.49,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 450 MG TABS,45754,CDM,250,RC,65862075360,NDC,,,facility,both,1,UN,,15.75,11.81,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,13668000901,NDC,,,facility,both,1.5,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,904608461,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,904608461,NDC,,,facility,both,3,UN,,2.37,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,13668000901,NDC,,,facility,both,1,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,904608461,NDC,,,facility,both,4,UN,,1.86,1.4,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,904608461,NDC,,,facility,both,2,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,904608461,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,13668000901,NDC,,,facility,both,2,UN,,3.35,2.51,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,904608461,NDC,,,facility,both,2.5,UN,,2.3,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG TABS,45871,CDM,250,RC,904608461,NDC,,,facility,both,1.5,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL 90 MCG/ACT AERS 18 G INHALER,4595,CDM,250,RC,MHS1GM,HCPCS,173068220,NDC,facility,both,1,GM,,5.71,4.28,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL 90 MCG/ACT AERS 6.7 G INHALER,4595,CDM,250,RC,MHS1GM,HCPCS,66758095985,NDC,facility,both,1,GM,,19.62,14.72,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL 90 MCG/ACT AERS 6.7 G INHALER,4595,CDM,250,RC,MHS1GM,HCPCS,54074287,NDC,facility,both,1,GM,,10.21,7.66,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL 90 MCG/ACT AERS 6.7 G INHALER,4595,CDM,250,RC,MHS1GM,HCPCS,69097014260,NDC,facility,both,1,GM,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL 90 MCG/ACT AERS 8 G INHALER,4595,CDM,250,RC,MHS1GM,HCPCS,173068224,NDC,facility,both,1,GM,,6.11,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL 90 MCG/ACT AERS 8.5 G INHALER,4595,CDM,250,RC,MHS1GM,HCPCS,68180096301,NDC,facility,both,1,GM,,6.68,5.01,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5ML SUSP,46092,CDM,250,RC,MHS5ML,HCPCS,65162064978,NDC,facility,both,5,ML,,10.02,7.51,,,,,,,,,,Gross Charge Type: Pharmacy
C Ext Mechanical Chest Wall Oscill Per Session,4609466901,CDM,460,RC,94669,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nocturnal Oximetry Recording,4609476201,CDM,460,RC,94762,HCPCS,,,facility,both,,,,339,254.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Attendance At Delivery,4609946401,CDM,460,RC,99464,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
DOXYCYCLINE MONOHYDRATE 100 MG TABS,46452,CDM,250,RC,60687034495,NDC,,,facility,both,0.5,UN,,9.85,7.39,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE MONOHYDRATE 100 MG TABS,46452,CDM,250,RC,23155013525,NDC,,,facility,both,2,UN,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE MONOHYDRATE 100 MG TABS,46452,CDM,250,RC,23155013525,NDC,,,facility,both,0.5,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE MONOHYDRATE 100 MG TABS,46452,CDM,250,RC,60687034495,NDC,,,facility,both,2,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE MONOHYDRATE 100 MG TABS,46452,CDM,250,RC,23155013525,NDC,,,facility,both,1,UN,,9.45,7.09,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE MONOHYDRATE 100 MG TABS,46452,CDM,250,RC,60687034495,NDC,,,facility,both,1,UN,,11.95,8.96,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE MONOHYDRATE 100 MG TABS,46452,CDM,250,RC,70710112307,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,51079017001,NDC,,,facility,both,2,UN,,5.72,4.29,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,904632361,NDC,,,facility,both,4,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,50268054115,NDC,,,facility,both,3,UN,,4.05,3.04,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,904632361,NDC,,,facility,both,1.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,50742061601,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,50742061601,NDC,,,facility,both,1,UN,,7.33,5.5,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,50268054115,NDC,,,facility,both,2,UN,,5.38,4.03,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,904632361,NDC,,,facility,both,3,UN,,4.37,3.27,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,50268054115,NDC,,,facility,both,1,UN,,9.17,6.88,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,50268054115,NDC,,,facility,both,4,UN,,3.39,2.54,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,904632361,NDC,,,facility,both,2,UN,,5.7,4.28,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,60687040201,NDC,,,facility,both,1,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,904632361,NDC,,,facility,both,0.5,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,904632361,NDC,,,facility,both,1,UN,,9.55,7.16,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,51079017001,NDC,,,facility,both,1,UN,,9.55,7.16,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 50 MG TB24,46464,CDM,250,RC,60687040201,NDC,,,facility,both,2,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 100 MG TB24,46465,CDM,250,RC,50268054215,NDC,,,facility,both,1,UN,,9.45,7.09,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 100 MG TB24,46465,CDM,250,RC,904632461,NDC,,,facility,both,1,UN,,9.53,7.15,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 100 MG TB24,46465,CDM,250,RC,904632461,NDC,,,facility,both,1.5,UN,,5.42,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 100 MG TB24,46465,CDM,250,RC,60687041301,NDC,,,facility,both,1,UN,,10.6,7.95,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 100 MG TB24,46465,CDM,250,RC,904632461,NDC,,,facility,both,2,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE 100 MG TB24,46465,CDM,250,RC,904632461,NDC,,,facility,both,3,UN,,4.58,3.44,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM 100 GM SOLR,46777,CDM,250,RC,66288110001,NDC,,,facility,both,0.00843,UN,,27.4,20.55,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM 100 GM SOLR 1 EACH FLEX CONT,46777,CDM,250,RC,66288110001,NDC,,,facility,both,0.03,UN,,33.45,25.09,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM 100 GM SOLR 1 EACH FLEX CONT,46777,CDM,250,RC,66288110001,NDC,,,facility,both,0.02,UN,,30.65,22.99,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML CONC 16.7 ML VIAL,46789,CDM,636,RC,J9267,HCPCS,61703034222,NDC,facility,both,1,ME,,1.11,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML CONC 16.7 ML VIAL,46789,CDM,636,RC,J9267,HCPCS,63323076316,NDC,facility,both,1,ME,,1.61,1.2,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML CONC 16.7 ML VIAL,46789,CDM,636,RC,J9267,HCPCS,703321601,NDC,facility,both,1,ME,,1.3,0.97,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML CONC 5 ML VIAL,46789,CDM,636,RC,J9267,HCPCS,61703034209,NDC,facility,both,1,ME,,1.33,1,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML CONC 50 ML VIAL,46789,CDM,636,RC,J9267,HCPCS,61703034250,NDC,facility,both,1,ME,,0.91,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
BRIMONIDINE 0.15 % SOLN 5 ML BOTTLE,46852,CDM,250,RC,23917705,NDC,,,facility,both,5,ML,,313.25,234.94,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 600-42.9 MG/5ML SUSR,46873,CDM,250,RC,MHS1ML,HCPCS,16714029401,NDC,facility,both,1,ML,,0.91,0.68,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERE 1.1 MG/ML SUSP,46964,CDM,255,RC,Q9957,HCPCS,11994001116,NDC,facility,both,1,ML,,190.35,142.76,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERE 1.1 MG/ML SUSP,46964,CDM,255,RC,Q9957,HCPCS,11994001104,NDC,facility,both,1,ML,,182.08,136.56,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERE 1.1 MG/ML SUSP,46964,CDM,636,RC,Q9957,HCPCS,11994001116,NDC,facility,both,1,ML,,180.15,135.11,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERE 1.1 MG/ML SUSP,46964,CDM,636,RC,Q9957,HCPCS,11994001104,NDC,facility,both,1,ML,,121.95,91.46,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERE 6.52 MG/ML IV SUSP,46964,CDM,11994001116,NDC,,,,,facility,both,1,ML,,177.8,133.35,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERE 6.52 MG/ML IV SUSP,46964,CDM,11994001104,NDC,,,,,facility,both,1,ML,,173.32,129.99,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL-ACETAMINOPHEN 37.5-325 MG TABS,46987,CDM,250,RC,53746061701,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL-ACETAMINOPHEN 37.5-325 MG TABS,46987,CDM,250,RC,53746061701,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML SOLR,47009,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,both,1,ME,,249.92,187.44,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML SOLR 1 EACH VIAL,47009,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,both,1,ME,,198.18,148.64,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG TBEC,47192,CDM,250,RC,60687072511,NDC,,,facility,both,1,UN,,9.6,7.2,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG TBEC,47192,CDM,250,RC,50268058515,NDC,,,facility,both,1,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG TBEC,47192,CDM,250,RC,60687072511,NDC,,,facility,both,2,UN,,5.75,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
TERBINAFINE 1 % CREA 30 G TUBE,47193,CDM,250,RC,MHS1GM,HCPCS,51672208002,NDC,facility,both,1,GM,,1.78,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
TERBINAFINE 1 % CREA 30 G TUBE,47193,CDM,250,RC,MHS1GM,HCPCS,49348079072,NDC,facility,both,1,GM,,1.64,1.23,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,60687062301,NDC,,,facility,both,3,UN,,4.73,3.55,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,33342006310,NDC,,,facility,both,0.5,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,60687062301,NDC,,,facility,both,2,UN,,6.08,4.56,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,33342006310,NDC,,,facility,both,1,UN,,8.07,6.05,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,33342006310,NDC,,,facility,both,3,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,60687062301,NDC,,,facility,both,4,UN,,4.04,3.03,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,33342006310,NDC,,,facility,both,4,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,33342006310,NDC,,,facility,both,2,UN,,4.57,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,60687062301,NDC,,,facility,both,0.5,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 80 MG TABS,47202,CDM,250,RC,60687062301,NDC,,,facility,both,1,UN,,9.71,7.28,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.22% NACL 5-0.2 % SOLN,4724,CDM,250,RC,MHS250ML,HCPCS,338007704,NDC,facility,both,250,ML,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % AND 0.22% NACL 5-0.2 % SOLN,4724,CDM,250,RC,MHS250ML,HCPCS,990792409,NDC,facility,both,250,ML,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAPS,4727,CDM,250,RC,42292001820,NDC,,,facility,both,3,UN,,3.57,2.67,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAPS,4727,CDM,250,RC,904595961,NDC,,,facility,both,3,UN,,3.03,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAPS,4727,CDM,250,RC,904595961,NDC,,,facility,both,6,UN,,1.76,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAPS,4727,CDM,250,RC,42292001820,NDC,,,facility,both,4,UN,,2.91,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAPS,4727,CDM,250,RC,904595961,NDC,,,facility,both,4,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAPS,4727,CDM,250,RC,42292001820,NDC,,,facility,both,2,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAPS,4727,CDM,250,RC,904595961,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAPS,4727,CDM,250,RC,904595961,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 1 % SOLN 30 ML BOTTLE,4729,CDM,250,RC,45802056201,NDC,,,facility,both,30,ML,,62.45,46.84,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL 0.63 MG/3ML NEBU,47315,CDM,636,RC,J7613,HCPCS,487030101,NDC,facility,both,1,ME,,10.76,8.07,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,47315,CDM,487030101,NDC,,,,,facility,both,1,ML,,13.95,10.46,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL 1.25 MG/3ML NEBU,47316,CDM,250,RC,J7613,HCPCS,487990425,NDC,facility,both,1,ME,,5.61,4.21,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,47316,CDM,487990401,NDC,,,,,facility,both,1,ML,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,64850051101,NDC,,,facility,both,1,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,64850051101,NDC,,,facility,both,3,UN,,2.58,1.94,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,228305911,NDC,,,facility,both,5,UN,,7.85,5.89,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,31722018601,NDC,,,facility,both,3,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,228305911,NDC,,,facility,both,2,UN,,9.52,7.14,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,31722018601,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,228305911,NDC,,,facility,both,3,UN,,8.67,6.5,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,228305911,NDC,,,facility,both,6,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,64850051101,NDC,,,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG CP24,47325,CDM,250,RC,228305911,NDC,,,facility,both,1,UN,,12.15,9.11,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,0.25,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,6,UN,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,4,UN,,2.58,1.93,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,7,UN,,1.74,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,FAMRXNC,HCPCS,60687011301,NDC,facility,both,2,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,1,UN,,7.89,5.91,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,228212710,NDC,,,facility,both,2,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,58657064701,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,9,UN,,1.48,1.11,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,228212710,NDC,,,facility,both,3,UN,,1.93,1.45,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,58657064701,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,3,UN,,3.22,2.41,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,228212710,NDC,,,facility,both,4,UN,,0.18,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,228212710,NDC,,,facility,both,1.5,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,2,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,58657064701,NDC,,,facility,both,3,UN,,2.23,1.67,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,1.5,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,228212710,NDC,,,facility,both,9,UN,,0.84,0.63,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,58657064701,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,228212710,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,228212710,NDC,,,facility,both,6,UN,,1.18,0.88,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,5,UN,,2.19,1.64,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,60687011301,NDC,,,facility,both,0.5,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,228212710,NDC,,,facility,both,0.5,UN,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG TABS,4756,CDM,250,RC,228212710,NDC,,,facility,both,7,UN,,0.17,0.13,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 7.5-325 MG TABS,47605,CDM,250,RC,904709461,NDC,,,facility,both,2,UN,,3.62,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 7.5-325 MG TABS,47605,CDM,250,RC,904709461,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 7.5-325 MG TABS,47605,CDM,250,RC,406052262,NDC,,,facility,both,1,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 10-325 MG TABS,47606,CDM,250,RC,42858010401,NDC,,,facility,both,1,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 10-325 MG TABS,47606,CDM,250,RC,406052362,NDC,,,facility,both,2,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 10-325 MG TABS,47606,CDM,250,RC,904709561,NDC,,,facility,both,0.5,UN,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 10-325 MG TABS,47606,CDM,250,RC,42858010401,NDC,,,facility,both,2,UN,,2.82,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 10-325 MG TABS,47606,CDM,250,RC,406052362,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 10-325 MG TABS,47606,CDM,250,RC,42858010401,NDC,,,facility,both,0.5,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 10-325 MG TABS,47606,CDM,250,RC,904709561,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 10-325 MG TABS,47606,CDM,250,RC,904709561,NDC,,,facility,both,2,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE 3.75 MG TABS,4765,CDM,250,RC,51672404201,NDC,,,facility,both,2,UN,,6.82,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE 3.75 MG TABS,4765,CDM,250,RC,51672404201,NDC,,,facility,both,1,UN,,9.45,7.09,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE 7.5 MG TABS,4766,CDM,250,RC,51672404301,NDC,,,facility,both,1,UN,,11.1,8.32,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE 7.5 MG TABS,4766,CDM,250,RC,51672404301,NDC,,,facility,both,2,UN,,8.48,6.36,,,,,,,,,,Gross Charge Type: Pharmacy
DESLORATADINE 5 MG TABS,47756,CDM,250,RC,68180015301,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 17 G PACK,47788,CDM,250,RC,MHS1EA,HCPCS,62559015710,NDC,facility,both,1,EA,,10.06,7.55,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 17 G PACK,47788,CDM,250,RC,MHS1EA,HCPCS,904693181,NDC,facility,both,1,EA,,10.99,8.24,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 17 G PACK,47788,CDM,250,RC,MHS1EA,HCPCS,69784018010,NDC,facility,both,1,EA,,11.5,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 17 G PACK,47788,CDM,250,RC,MHS1EA,HCPCS,51079030630,NDC,facility,both,1,EA,,10.95,8.21,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 17 G PACK,47788,CDM,250,RC,MHS1EA,HCPCS,62559015717,NDC,facility,both,1,EA,,10.17,7.63,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % CREA 15 G TUBE,4779,CDM,250,RC,MHS1GM,HCPCS,45802043401,NDC,facility,both,1,GM,,2.83,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % CREA 30 G TUBE,4779,CDM,250,RC,MHS1GM,HCPCS,68462018135,NDC,facility,both,1,GM,,1.86,1.39,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % CREA 30 G TUBE,4779,CDM,250,RC,MHS1GM,HCPCS,49348027972,NDC,facility,both,1,GM,,1.47,1.1,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % CREA 30 G TUBE,4779,CDM,250,RC,MHS1GM,HCPCS,51672200202,NDC,facility,both,1,GM,,1.32,0.99,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % CREA 30 G TUBE,4779,CDM,250,RC,MHS1GM,HCPCS,45802043411,NDC,facility,both,1,GM,,1.32,0.99,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN IMMUNE FAB SOLR 1 EACH VIAL,47790,CDM,636,RC,J1162,HCPCS,50633012011,NDC,facility,both,1,EA,,10210.14,7657.6,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % SOLN,4780,CDM,250,RC,71399050003,NDC,,,facility,both,30,ML,,62,46.5,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % SOLN,4780,CDM,250,RC,70954003620,NDC,,,facility,both,30,ML,,113.55,85.16,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % SOLN 30 ML BOTTLE,4780,CDM,250,RC,51672126003,NDC,,,facility,both,30,ML,,122.7,92.02,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250ML SOLN,47803,CDM,636,RC,J2280,HCPCS,67457032325,NDC,facility,both,100,ME,,40.6,30.45,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GM SOLR 1 EACH VIAL,47804,CDM,636,RC,J1335,HCPCS,55150028220,NDC,facility,both,500,ME,,70.9,53.18,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GM SOLR 1 EACH VIAL,47804,CDM,636,RC,J1335,HCPCS,42023022110,NDC,facility,both,500,ME,,88.77,66.58,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % CREA 45 G TUBE,4781,CDM,250,RC,51672200306,NDC,,,facility,both,45,GR,,31.75,23.81,,,,,,,,,,Gross Charge Type: Pharmacy
PIMECROLIMUS 1 % CREA 30 G TUBE,47821,CDM,250,RC,MHS1GM,HCPCS,187510001,NDC,facility,both,1,GM,,15.55,11.66,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 2.5 MG/0.5 ML SOLN,47986,CDM,636,RC,J1652,HCPCS,67457058210,NDC,facility,both,0.5,ME,,18.87,14.15,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Percutaenous Transluminal Coronary Lithotripsy Add-On,4800715T01,CDM,480,RC,0715T,HCPCS,,,facility,both,,,,0.01,0.01,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc  Prgrmg Dev Eval Ldls Pm Sys 2Chmbr In Person,4800804T01,CDM,480,RC,0804T,HCPCS,,,facility,both,,,,91,68.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cardiovascular Strs Tst Xers&/Or Rx Cont Ecg I And R Only,4809301801,CDM,480,RC,93018,HCPCS,,,facility,both,,,,43,32.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Programing Device Eval Pm/Ldls Pm,4809327901,CDM,480,RC,93279,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Pacer Program Dual,4809328001,CDM,480,RC,93280,HCPCS,,,facility,both,,,,135,101.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Pacer Program Multiple,4809328101,CDM,480,RC,93281,HCPCS,,,facility,both,,,,144,108,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Programing Eval Implantable Defib Single,4809328201,CDM,480,RC,93282,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc  Programing Eval Implantable Defib  Multiple,4809328401,CDM,480,RC,93284,HCPCS,,,facility,both,,,,187,140.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Programing Device Eval Scrms Phys/Qhp In Person,4809328501,CDM,480,RC,93285,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Implant Cv Monitor Inter,4809329001,CDM,480,RC,93290,HCPCS,,,facility,both,,,,88,66,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Injection Procedure During Cardiac Catheterization Inc Imaging S&I Interpretation And Report For,4809357301,CDM,480,RC,93573,HCPCS,,,facility,both,,,,2231,1673.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Intra Atrial Pacing,4809361001,CDM,480,RC,93610,HCPCS,,,facility,both,,,,7827,5870.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Inter Devc Remote 30D,480G206601,CDM,480,RC,G2066,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Transcatheter Insert Permanent Dual Chamber Leadless Pacemaker Inc Imaging Guidance And Device Ev,4810795T01,CDM,481,RC,0795T,HCPCS,,,facility,both,,,,47046,35284.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Transcatheter Insert Permanent Dual Chamber Leadless Pacemaker Inc Imaging Guidance And Device Ev,4810796T01,CDM,481,RC,0796T,HCPCS,,,facility,both,,,,47046,35284.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Transcatheter Insert Permanent Dual Chamber Leadless Pacemaker Inc Imaging Guidance And Device Ev,4810797T01,CDM,481,RC,0797T,HCPCS,,,facility,both,,,,47046,35284.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Insertion Permanent Single Chamber Leadless Pacemaker, Right Atrial, Inc Imaging Guidance, Device",4810823T01,CDM,481,RC,0823T,HCPCS,,,facility,both,,,,46462,34846.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Removal Permanent Single Chamber Leadless Pacemaker, Right Atrial, Inc Imaging Guidance",4810824T01,CDM,481,RC,0824T,HCPCS,,,facility,both,,,,7601,5700.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Removal And Replacement Permanent Single Chamber Leadless Pacemaker, Right Atrial, Inc Imaging Gu",4810825T01,CDM,481,RC,0825T,HCPCS,,,facility,both,,,,46462,34846.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ecmo Implnt Ventricul Dev Sngl,4813397501,CDM,481,RC,33975,HCPCS,,,facility,both,,,,10264,7698,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Insertion Ventricular Assist Device,Percutaneous Inc S&I, Right Heart, Venous Access Only",4813399501,CDM,481,RC,33995,HCPCS,,,facility,both,,,,1011,758.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Percutaneous Transluminal Coronary Lithotripsy Add-On,4819297201,CDM,481,RC,92972,HCPCS,,,facility,both,,,,1847,1385.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ifr Or Ffr W/O Pharmacologically Induced Stress,4819379901,CDM,481,RC,93799,HCPCS,,,facility,both,,,,5198,3898.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Revascularization,Endovascular, Open Or Percutaneous , Tibial/Peroneal Artery(Ies),W/Intravascula",481C977201,CDM,481,RC,C9772,HCPCS,,,facility,both,,,,26562,19921.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Revascularization,Endovascular,Open Or Percutaneous,Tibial/Peroneal Artery(Ies),W/Intravascular L",481C977301,CDM,481,RC,C9773,HCPCS,,,facility,both,,,,42338,31753.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Revascularization,Endovascular, Open Or Percutaneous,Tibial/Peroneal Artery(Ies),W/Intravascular",481C977401,CDM,481,RC,C9774,HCPCS,,,facility,both,,,,42338,31753.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Revascularization,Endovascular,Open/Percutaneous,Tibial/Peroneal Artery(Ies),W/Intravascular Lith",481C977501,CDM,481,RC,C9775,HCPCS,,,facility,both,,,,32805,24603.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cardiovascular Stress Test,4829301601,CDM,482,RC,93016,HCPCS,,,facility,both,,,,171,128.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
PAMIDRONATE 3 MG/ML SOLN 10 ML VIAL,48368,CDM,636,RC,J2430,HCPCS,67457043010,NDC,facility,both,30,ME,,58.69,44.02,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 3 MG/ML SOLN 10 ML VIAL,48368,CDM,636,RC,J2430,HCPCS,61703032418,NDC,facility,both,30,ME,,60.62,45.47,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Complete Tthrc Echo Congenital Cardiac Anomaly W/ Contrast,4839330301,CDM,483,RC,93303,HCPCS,,,facility,both,,,,3000,2250,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc F-Up/Limited Tthrc Echo Congenital Car Anomaly W/ Contrast,4839330401,CDM,483,RC,93304,HCPCS,,,facility,both,,,,3000,2250,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo Img/Pstprocesng During Trnssphgl Echoc/Trnsthrcc Echo For Cngntl Crd Anmls To Assmnt Of Crd,4839331901,CDM,483,RC,93319,HCPCS,,,facility,both,,,,711,533.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo Transthorc R-T 2D W/Wo M-Mode Rec F-Up/Lmtd W/ Contrast,483C892401,CDM,483,RC,93308,HCPCS,,,facility,both,,,,843,632.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc  Echo Transesophag R-T 2D W/Prb Img Acquisj I&R W/ Contrast,483C892501,CDM,483,RC,93312,HCPCS,,,facility,both,,,,2900,2175,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo Tthrc R-T 2D W/Wo M-Mode Complete Rest&St W/ Contrast,483C892801,CDM,483,RC,93350,HCPCS,,,facility,both,,,,1268,951,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo Tthrc R-T 2D W/Wom-Mode Compl Spec&Colr D W/ Contrast,483C892901,CDM,483,RC,93306,HCPCS,,,facility,both,,,,2493,1869.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo Tthrc R-T 2D W/Wom-Mode Compl Spec&Colr D W/ Contrast,483C892901,CDM,483,RC,93306,HCPCS,,,facility,both,,,,1438,1078.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
METHYLPHENIDATE 27 MG TBCR,48461,CDM,250,RC,406012701,NDC,,,facility,both,1,UN,,13.05,9.79,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 27 MG TBCR,48461,CDM,250,RC,406012701,NDC,,,facility,both,2,UN,,10.42,7.82,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 27 MG TBCR,48461,CDM,250,RC,13811070710,NDC,,,facility,both,2,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN,48525,CDM,250,RC,49230020992,NDC,,,facility,both,500,ML,,29.15,21.86,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN,48525,CDM,250,RC,49230020950,NDC,,,facility,both,4000,ML,,46.75,35.06,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN,48525,CDM,250,RC,49230020950,NDC,,,facility,both,1000,ML,,26.78,20.08,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN,48525,CDM,250,RC,49230020992,NDC,,,facility,both,2000,ML,,60.35,45.26,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN,48525,CDM,250,RC,49230020950,NDC,,,facility,both,3400,ML,,42.7,32.02,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN,48525,CDM,250,RC,49230020950,NDC,,,facility,both,5000,ML,,55.47,41.61,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN 2,000 ML FLEX CONT",48525,CDM,250,RC,49230020992,NDC,,,facility,both,1000,ML,,39.95,29.96,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN 2,000 ML FLEX CONT",48525,CDM,250,RC,49230020992,NDC,,,facility,both,2000,ML,,60.35,45.26,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN 5,000 ML FLEX CONT",48525,CDM,250,RC,49230020950,NDC,,,facility,both,1000,ML,,25.35,19.01,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN 5,000 ML FLEX CONT",48525,CDM,250,RC,49230020950,NDC,,,facility,both,3000,ML,,43.35,32.51,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN 5,000 ML FLEX CONT",48525,CDM,250,RC,49230020950,NDC,,,facility,both,5000,ML,,54.49,40.87,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 2.5% LOW CALCIUM PERITONEAL DIALYSIS SOLN 394 MOSM/L SOLN 5,000 ML FLEX CONT",48525,CDM,250,RC,49230020950,NDC,,,facility,both,2000,ML,,32.8,24.6,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 5 MG TABS,48567,CDM,250,RC,68462043630,NDC,,,facility,both,1,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 5 MG TABS,48567,CDM,250,RC,68462043630,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 5 MG TABS,48567,CDM,250,RC,68462043630,NDC,,,facility,both,4,UN,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 5 MG TABS,48567,CDM,250,RC,68462043630,NDC,,,facility,both,8,UN,,1.2,0.9,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 5 MG TABS,48567,CDM,250,RC,68462043630,NDC,,,facility,both,2,UN,,3.72,2.79,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG TABS,48568,CDM,250,RC,16729032115,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG TABS,48568,CDM,250,RC,68462043730,NDC,,,facility,both,2,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG TABS,48568,CDM,250,RC,16729032115,NDC,,,facility,both,2,UN,,3.78,2.83,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG TABS,48568,CDM,250,RC,68462043730,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG TABS,48568,CDM,250,RC,16729032115,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG TABS,48568,CDM,250,RC,68462043730,NDC,,,facility,both,1,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
BRIMONIDINE 0.2% 0.2 % SOLN,4861,CDM,250,RC,MHS1ML,HCPCS,24208041110,NDC,facility,both,1,ML,,3.94,2.95,,,,,,,,,,Gross Charge Type: Pharmacy
BRIMONIDINE 0.2% 0.2 % SOLN 5 ML BOTTLE,4861,CDM,250,RC,MHS1ML,HCPCS,24208041105,NDC,facility,both,1,ML,,9.94,7.46,,,,,,,,,,Gross Charge Type: Pharmacy
BRIMONIDINE 0.2% 0.2 % SOLN 5 ML BOTTLE,4861,CDM,250,RC,MHS1ML,HCPCS,70069023101,NDC,facility,both,1,ML,,7.03,5.27,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 7.5 MG KIT,48697,CDM,636,RC,J9217,HCPCS,62935075375,NDC,facility,both,7.5,ME,,416.82,312.62,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 7.5 MG KIT,48697,CDM,636,RC,J9217,HCPCS,62935075680,NDC,facility,both,7.5,ME,,466.45,349.84,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE 30 MG TABS,4874,CDM,250,RC,54024425,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE 30 MG TABS,4874,CDM,250,RC,54024424,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,31722018501,NDC,,,facility,both,2,UN,,4.02,3.02,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,70010002901,NDC,,,facility,both,4,UN,,2.28,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,406895101,NDC,,,facility,both,2,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,228306211,NDC,,,facility,both,5,UN,,8.59,6.44,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,406895101,NDC,,,facility,both,6,UN,,3.11,2.33,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,228306211,NDC,,,facility,both,3,UN,,9.42,7.06,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,228306211,NDC,,,facility,both,1,UN,,12.9,9.68,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,31722018501,NDC,,,facility,both,3,UN,,3.15,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,406895101,NDC,,,facility,both,3,UN,,3.97,2.97,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,406895101,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,228306211,NDC,,,facility,both,4,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,70010002901,NDC,,,facility,both,3,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG CP24,48805,CDM,250,RC,406895101,NDC,,,facility,both,4,UN,,3.54,2.65,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,60687040925,NDC,,,facility,both,2,UN,,5.78,4.33,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,60687040925,NDC,,,facility,both,0.5,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,245021311,NDC,,,facility,both,0.75,UN,,1.85,1.39,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,60687040925,NDC,,,facility,both,1,UN,,8.22,6.16,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,245021311,NDC,,,facility,both,1.25,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,60687040925,NDC,,,facility,both,1.5,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,245021311,NDC,,,facility,both,1,UN,,8.44,6.33,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,245021311,NDC,,,facility,both,0.5,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,245021311,NDC,,,facility,both,2,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,245021311,NDC,,,facility,both,1.5,UN,,5.62,4.22,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE 10 MG TABS,48883,CDM,250,RC,904681907,NDC,,,facility,both,1,UN,,10,7.5,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 2.5 MG TABS,48962,CDM,636,RC,J8610,HCPCS,47335023583,NDC,facility,both,2.5,ME,,12.83,9.62,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT SOLR,48974,CDM,636,RC,J0585,HCPCS,23923201,NDC,facility,both,1,UN,,12.44,9.33,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA (COSMETIC) 100 UNITS IM SOLR,48974,CDM,23923201,NDC,,,,,facility,both,1,EA,,11.15,8.36,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,68462057230,NDC,,,facility,both,2,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,16714019801,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,16714019801,NDC,,,facility,both,1,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,904659604,NDC,,,facility,both,4,UN,,15.38,11.53,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,904659604,NDC,,,facility,both,1,UN,,13.5,10.12,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,16714019801,NDC,,,facility,both,5,UN,,5.13,3.85,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,16714019801,NDC,,,facility,both,3,UN,,3.43,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,904659604,NDC,,,facility,both,3,UN,,16.27,12.2,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,904659604,NDC,,,facility,both,2,UN,,18.02,13.52,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,68462057230,NDC,,,facility,both,1,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 50 MG TABS,48981,CDM,250,RC,16714019801,NDC,,,facility,both,6,UN,,4.81,3.61,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG TABS,48982,CDM,250,RC,43547037803,NDC,,,facility,both,1.5,UN,,29.6,22.2,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG TABS,48982,CDM,250,RC,27241006303,NDC,,,facility,both,2,UN,,17.05,12.79,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG TABS,48982,CDM,250,RC,51079016503,NDC,,,facility,both,1.5,UN,,27.25,20.44,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG TABS,48982,CDM,250,RC,51079016503,NDC,,,facility,both,1,UN,,39.21,29.41,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG TABS,48982,CDM,250,RC,51079016503,NDC,,,facility,both,2,UN,,34.58,25.93,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG TABS,48982,CDM,250,RC,27241006303,NDC,,,facility,both,1.5,UN,,13.06,9.79,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG TABS,48982,CDM,250,RC,27241006303,NDC,,,facility,both,1,UN,,20.67,15.5,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG TABS,48982,CDM,250,RC,43547037803,NDC,,,facility,both,1,UN,,43,32.25,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG TABS,48982,CDM,250,RC,51079016503,NDC,,,facility,both,0.75,UN,,27.28,20.46,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE SOLR 1 EACH VIAL,48983,CDM,636,RC,J3465,HCPCS,49319028,NDC,facility,both,10,ME,,4.42,3.32,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE SOLR 1 EACH VIAL,48983,CDM,636,RC,J3465,HCPCS,781341694,NDC,facility,both,10,ME,,11.62,8.72,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE SOLR,49018,CDM,636,RC,J3486,HCPCS,43598084858,NDC,facility,both,10,ME,,52.59,39.44,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE SOLR,49018,CDM,636,RC,J3486,HCPCS,49392083,NDC,facility,both,10,ME,,102.07,76.55,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,49066,CDM,250,RC,16714047701,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,49066,CDM,250,RC,781183120,NDC,,,facility,both,1,UN,,9.75,7.31,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 500-125 MG TABS,49066,CDM,250,RC,16714047701,NDC,,,facility,both,0.5,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,49067,CDM,250,RC,781185220,NDC,,,facility,both,1,UN,,10.15,7.61,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,49067,CDM,250,RC,16714001401,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,49067,CDM,250,RC,65862050320,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,49067,CDM,250,RC,42571016242,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 875-125 MG TABS,49067,CDM,250,RC,42571016201,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 400-57 MG/5ML SUSR,49069,CDM,250,RC,MHS1ML,HCPCS,66685101201,NDC,facility,both,1,ML,,0.84,0.63,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG TABS,4913,CDM,250,RC,65162071009,NDC,,,facility,both,1,UN,,8.36,6.27,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,904642661,NDC,,,facility,both,4,UN,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,68084061701,NDC,,,facility,both,1,UN,,7.26,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,904642661,NDC,,,facility,both,2.5,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,65862037401,NDC,,,facility,both,1,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,68084061701,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,904642661,NDC,,,facility,both,3,UN,,2.83,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,904642661,NDC,,,facility,both,1,UN,,6.67,5,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,904642661,NDC,,,facility,both,2,UN,,3.86,2.9,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,904642661,NDC,,,facility,both,0.5,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,65862037401,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,68084061701,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,904642661,NDC,,,facility,both,1.5,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG TABS,49352,CDM,250,RC,68084061701,NDC,,,facility,both,1.5,UN,,4.08,3.06,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,51660014030,NDC,,,facility,both,0.5,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,51660014030,NDC,,,facility,both,3,UN,,3.6,2.7,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,33342006207,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,33342006207,NDC,,,facility,both,4,UN,,2.79,2.09,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,43547036703,NDC,,,facility,both,4,UN,,2.42,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,60687061211,NDC,,,facility,both,4,UN,,3.61,2.71,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,43547036703,NDC,,,facility,both,8,UN,,1.46,1.09,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,33342006207,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,60687061211,NDC,,,facility,both,2,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,43547036703,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,51660014030,NDC,,,facility,both,4,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,33342006207,NDC,,,facility,both,0.5,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,51660014030,NDC,,,facility,both,1,UN,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,60687061211,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,60687061211,NDC,,,facility,both,0.5,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,43547036703,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 40 MG TABS,49381,CDM,250,RC,43547036703,NDC,,,facility,both,2,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE SOLR 1 EACH VIAL,49432,CDM,636,RC,J2783,HCPCS,24515010,NDC,facility,both,0.5,ME,,1057.36,793.02,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NOVOLOG 70/30 MIX 100 UNITS/ML SUSP,49501,CDM,636,RC,J1815,HCPCS,169368512,NDC,facility,both,5,UN,,9.09,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NOVOLOG 70/30 MIX 100 UNITS/ML SUSP,49501,CDM,637,RC,J1815,HCPCS,169368512,NDC,facility,both,5,UN,,7.51,5.64,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG KIT,49504,CDM,636,RC,J9217,HCPCS,62935022305,NDC,facility,both,7.5,ME,,418.6,313.95,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG KIT,49504,CDM,636,RC,J9217,HCPCS,62935022710,NDC,facility,both,7.5,ME,,336.57,252.42,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-CLAVULANATE 1000-62.5 MG TB12,49744,CDM,250,RC,781194339,NDC,,,facility,both,2,UN,,12.92,9.69,,,,,,,,,,Gross Charge Type: Pharmacy
METAXALONE 800 MG TABS,49845,CDM,250,RC,527143501,NDC,,,facility,both,0.5,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
METAXALONE 800 MG TABS,49845,CDM,250,RC,55111065001,NDC,,,facility,both,0.5,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
METAXALONE 800 MG TABS,49845,CDM,250,RC,527143501,NDC,,,facility,both,1,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
METAXALONE 800 MG TABS,49845,CDM,250,RC,55111065001,NDC,,,facility,both,1,UN,,10.9,8.18,,,,,,,,,,Gross Charge Type: Pharmacy
DUTASTERIDE 0.5 MG CAPS,49969,CDM,250,RC,31722013130,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
Hc-Fee For Each Visit To Niach,5000000001,CDM,,,,,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
EZETIMIBE 10 MG TABS,50033,CDM,250,RC,60687037311,NDC,,,facility,both,1,UN,,26.1,19.58,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG TABS,50033,CDM,250,RC,69238115403,NDC,,,facility,both,1,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG TABS,50033,CDM,250,RC,68382077306,NDC,,,facility,both,1,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG TABS,50033,CDM,250,RC,68382077306,NDC,,,facility,both,0.5,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,60687017901,NDC,,,facility,both,3,UN,,10.72,8.04,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,50268008911,NDC,,,facility,both,0.5,UN,,12.55,9.41,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,16714014301,NDC,,,facility,both,2,UN,,4.09,3.07,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,13668021830,NDC,,,facility,both,1,UN,,10.9,8.18,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,60687017901,NDC,,,facility,both,2,UN,,12.32,9.24,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,16714014301,NDC,,,facility,both,0.5,UN,,6.37,4.78,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,50268008911,NDC,,,facility,both,2,UN,,12.4,9.3,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,50268008911,NDC,,,facility,both,3,UN,,10.8,8.1,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,65862066330,NDC,,,facility,both,2,UN,,5.62,4.22,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,50268008911,NDC,,,facility,both,1.5,UN,,10.48,7.86,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,16714014301,NDC,,,facility,both,1.5,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,60687017901,NDC,,,facility,both,1,UN,,16.8,12.6,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,16714014301,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,50268008911,NDC,,,facility,both,1,UN,,16.51,12.38,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG TABS,50254,CDM,250,RC,16714014301,NDC,,,facility,both,3,UN,,2.97,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG TABS,50255,CDM,250,RC,13668021930,NDC,,,facility,both,1,UN,,10.9,8.18,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG TABS,50255,CDM,250,RC,63739007833,NDC,,,facility,both,2,UN,,16.62,12.47,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG TABS,50255,CDM,250,RC,13668021930,NDC,,,facility,both,0.6667,UN,,9.85,7.39,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG TABS,50255,CDM,250,RC,13668021930,NDC,,,facility,both,2,UN,,6.92,5.19,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG TABS,50255,CDM,250,RC,16714014401,NDC,,,facility,both,1,UN,,7.85,5.89,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG TABS,50255,CDM,250,RC,16714014401,NDC,,,facility,both,0.4,UN,,0.75,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG TABS,50255,CDM,250,RC,63739007833,NDC,,,facility,both,1,UN,,21.4,16.05,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 20 MG TABS,50256,CDM,250,RC,60687020221,NDC,,,facility,both,1,UN,,30.4,22.8,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 20 MG TABS,50256,CDM,250,RC,16714014501,NDC,,,facility,both,1,UN,,2.79,2.09,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 20 MG TABS,50256,CDM,250,RC,16714014501,NDC,,,facility,both,1.25,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 250 MG TB24,50303,CDM,250,RC,51079076608,NDC,,,facility,both,4,UN,,4.79,3.59,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 250 MG TB24,50303,CDM,250,RC,904636361,NDC,,,facility,both,1,UN,,9.44,7.08,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 250 MG TB24,50303,CDM,250,RC,904636361,NDC,,,facility,both,2,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 250 MG TB24,50303,CDM,250,RC,51079076608,NDC,,,facility,both,2,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 250 MG TB24,50303,CDM,250,RC,904636361,NDC,,,facility,both,4,UN,,4.48,3.36,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 250 MG TB24,50303,CDM,250,RC,51079076608,NDC,,,facility,both,1,UN,,10.85,8.14,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX SR 250 MG TB24,50303,CDM,250,RC,904636361,NDC,,,facility,both,3,UN,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 10 MG CAPS,50330,CDM,250,RC,31722071430,NDC,,,facility,both,3,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 10 MG CAPS,50330,CDM,250,RC,60505283003,NDC,,,facility,both,1,UN,,9.31,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 10 MG CAPS,50330,CDM,250,RC,31722071430,NDC,,,facility,both,1,UN,,11.6,8.7,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE HCL 18 MG CAPS,50331,CDM,250,RC,16714075601,NDC,,,facility,both,1,UN,,12.7,9.52,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 25 MG CAPS,50332,CDM,250,RC,31722071630,NDC,,,facility,both,1,UN,,11.6,8.7,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 25 MG CAPS,50332,CDM,250,RC,50268005711,NDC,,,facility,both,2,UN,,10.55,7.91,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 25 MG CAPS,50332,CDM,250,RC,50268005711,NDC,,,facility,both,1,UN,,14.9,11.18,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 25 MG CAPS,50332,CDM,250,RC,16714075701,NDC,,,facility,both,1,UN,,12.7,9.52,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 40 MG CAPS,50333,CDM,250,RC,60687032625,NDC,,,facility,both,1,UN,,19.75,14.81,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 40 MG CAPS,50333,CDM,250,RC,16714075801,NDC,,,facility,both,1,UN,,9.98,7.49,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 40 MG CAPS,50333,CDM,250,RC,64980037603,NDC,,,facility,both,2,UN,,11.28,8.46,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 40 MG CAPS,50333,CDM,250,RC,64980037603,NDC,,,facility,both,1,UN,,12.78,9.59,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 40 MG CAPS,50333,CDM,250,RC,60687032625,NDC,,,facility,both,2,UN,,15.1,11.32,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 60 MG CAPS,50334,CDM,250,RC,16714075901,NDC,,,facility,both,1,UN,,13.1,9.82,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 60 MG CAPS,50334,CDM,250,RC,55111052230,NDC,,,facility,both,1,UN,,14.1,10.58,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE 60 MG CAPS,50334,CDM,250,RC,50268005911,NDC,,,facility,both,1,UN,,15.35,11.51,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS,50388,CDM,250,RC,406012362,NDC,,,facility,both,3,UN,,2.38,1.79,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS,50388,CDM,250,RC,406012362,NDC,,,facility,both,1.5,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS,50388,CDM,250,RC,406012362,NDC,,,facility,both,2,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS,50388,CDM,250,RC,406012362,NDC,,,facility,both,0.5,UN,,5.55,4.16,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS,50388,CDM,250,RC,406012362,NDC,,,facility,both,1,UN,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG TABS,50425,CDM,250,RC,406012462,NDC,,,facility,both,0.5,UN,,5.5,4.12,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG TABS,50425,CDM,250,RC,406012462,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG TABS,50425,CDM,250,RC,406012462,NDC,,,facility,both,1,UN,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6ML LIQD,50478,CDM,250,RC,536130375,NDC,,,facility,both,0.3,ML,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6ML LIQD,50478,CDM,250,RC,536130375,NDC,,,facility,both,0.6,ML,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6ML LIQD,50478,CDM,250,RC,536130375,NDC,,,facility,both,1.2,ML,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6ML LIQD,50478,CDM,250,RC,536130375,NDC,,,facility,both,1.875,ML,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6ML LIQD,50478,CDM,250,RC,536130375,NDC,,,facility,both,2.7,ML,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6ML LIQD,50478,CDM,250,RC,536130375,NDC,,,facility,both,2.4,ML,,5.4,4.05,,,,,,,,,,Gross Charge Type: Pharmacy
ELETRIPTAN 40 MG TABS,50583,CDM,250,RC,93831118,NDC,,,facility,both,1,UN,,39.65,29.74,,,,,,,,,,Gross Charge Type: Pharmacy
ELETRIPTAN 40 MG TABS,50583,CDM,250,RC,59651010506,NDC,,,facility,both,1,UN,,28.95,21.71,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SUBL,50610,CDM,250,RC,62175045232,NDC,,,facility,both,3,UN,,4.33,3.25,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SUBL,50610,CDM,250,RC,62175045232,NDC,,,facility,both,2,UN,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SUBL,50610,CDM,250,RC,62175045232,NDC,,,facility,both,0.5,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SUBL,50610,CDM,250,RC,62175045232,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,62175045832,NDC,,,facility,both,2,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,65162041503,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,62175045832,NDC,,,facility,both,0.75,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,62175045832,NDC,,,facility,both,3,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,62175045832,NDC,,,facility,both,0.5,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,62175045832,NDC,,,facility,both,1,UN,,7.9,5.92,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,62175045832,NDC,,,facility,both,2.5,UN,,4,3,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,62175045832,NDC,,,facility,both,1.5,UN,,4.62,3.47,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,65162041503,NDC,,,facility,both,0.5,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SUBL,50611,CDM,250,RC,65162041503,NDC,,,facility,both,2,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG LOZG,50666,CDM,250,RC,49348085216,NDC,,,facility,both,2,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG LOZG,50666,CDM,250,RC,113034405,NDC,,,facility,both,2,UN,,4.92,3.69,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG LOZG,50666,CDM,250,RC,113034403,NDC,,,facility,both,1,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG LOZG,50666,CDM,250,RC,70677117601,NDC,,,facility,both,1,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG LOZG,50666,CDM,250,RC,113034403,NDC,,,facility,both,2,UN,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG LOZG,50666,CDM,250,RC,70677008701,NDC,,,facility,both,1,UN,,8.05,6.04,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG LOZG,50666,CDM,250,RC,49348085216,NDC,,,facility,both,1,UN,,8.16,6.12,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 2 MG LOZG,50666,CDM,250,RC,113034405,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG LOZG,50667,CDM,250,RC,43598048724,NDC,,,facility,both,1,UN,,8.4,6.3,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG LOZG,50667,CDM,250,RC,113087305,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG LOZG,50667,CDM,250,RC,49348085316,NDC,,,facility,both,0.5,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG LOZG,50667,CDM,250,RC,45802087305,NDC,,,facility,both,1,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG LOZG,50667,CDM,250,RC,70677117701,NDC,,,facility,both,1,UN,,10.2,7.65,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG LOZG,50667,CDM,250,RC,113087305,NDC,,,facility,both,0.5,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG LOZG,50667,CDM,250,RC,49348085316,NDC,,,facility,both,1,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 4 MG LOZG,50667,CDM,250,RC,43598048724,NDC,,,facility,both,0.5,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 SOLN 10 ML BOTTLE,50711,CDM,250,RC,61314064610,NDC,,,facility,both,10,ML,,147.45,110.59,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,60505311100,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,68084072301,NDC,,,facility,both,0.5,UN,,7.6,5.7,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,60505311100,NDC,,,facility,both,1,UN,,6.06,4.55,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,68084072301,NDC,,,facility,both,1.5,UN,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,68084072301,NDC,,,facility,both,1,UN,,8.12,6.09,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,60505311100,NDC,,,facility,both,3,UN,,3.03,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,68084072301,NDC,,,facility,both,2,UN,,4.92,3.69,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,60505311100,NDC,,,facility,both,0.5,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,60505311100,NDC,,,facility,both,1.5,UN,,4.05,3.04,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,60505311100,NDC,,,facility,both,4,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 5 MG TABS,5090,CDM,250,RC,68084072301,NDC,,,facility,both,4,UN,,2.99,2.24,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG TABS,5093,CDM,250,RC,68084074001,NDC,,,facility,both,0.5,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG TABS,5093,CDM,250,RC,904637661,NDC,,,facility,both,1.5,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG TABS,5093,CDM,250,RC,904637661,NDC,,,facility,both,2,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG TABS,5093,CDM,250,RC,904637661,NDC,,,facility,both,0.5,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG TABS,5093,CDM,250,RC,904637661,NDC,,,facility,both,4,UN,,2.94,2.2,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG TABS,5093,CDM,250,RC,904637661,NDC,,,facility,both,3,UN,,3.58,2.69,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG TABS,5093,CDM,250,RC,68084074001,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG TABS,5093,CDM,250,RC,904637661,NDC,,,facility,both,1,UN,,8.64,6.48,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG TABS,5093,CDM,250,RC,68084074001,NDC,,,facility,both,2,UN,,5.52,4.14,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 7.5 MG TABS,5094,CDM,250,RC,43598016530,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 7.5 MG TABS,5094,CDM,250,RC,43598016530,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 7.5 MG TABS,5094,CDM,250,RC,43598016530,NDC,,,facility,both,4,UN,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Acne Surgery,5101004001,CDM,510,RC,10040,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Debride Infected Skin Tc,5101100001,CDM,510,RC,11000,HCPCS,,,facility,both,,,,549,411.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Remove Skin Tags Add-On Tc,5101120101,CDM,510,RC,11201,HCPCS,,,facility,both,,,,4,3,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Shaving Skin Lesion 1 Trunk, Arm, Leg Diam 0.5Cm Or Less",5101130001,CDM,510,RC,11300,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Shaving Of Lesion 0.6-1.0Cm Tc,5101130101,CDM,510,RC,11301,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Shvg Skn Lesion 1 Trunk, Arm, Leg Diam 1.1-2.0 Cm",5101130201,CDM,510,RC,11302,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Shave Of Lesion Dia>2.0Cm Tc,5101130301,CDM,510,RC,11303,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Shaving Skin Lesion 1 Scalp, Neck, Hands, Feet, Genitalia Diam 0.5 Cm Or Less",5101130501,CDM,510,RC,11305,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Shave Skin Lesion 0.6-1.0Cm Tc,5101130601,CDM,510,RC,11306,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Shaving Skin Lesion 1 Scalp, Neck, Hands, Feet, Genitalia Diam 1.1-2.0 Cm",5101130701,CDM,510,RC,11307,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Shave Skin Lesion>2.0 Cm,5101130801,CDM,510,RC,11308,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Shaving Skin Lesion 1 Face, Ears, Eyelids, Nose, Lips, Mouth Diam 0.5 Cm Or Less",5101131001,CDM,510,RC,11310,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Shave Skin Lesion 0.6-1.0 Cm,5101131101,CDM,510,RC,11311,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Shave Skin Lesion 1.1-2.0Cm,5101131201,CDM,510,RC,11312,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Shave Skin Lesion >2.0 Cm,5101131301,CDM,510,RC,11313,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Excision B9 Lesion2.1-3.0Cm Tc,5101140301,CDM,510,RC,11403,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Removal Of Skin Lesion Tc,5101140401,CDM,510,RC,11404,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Remove B9 Skin Lesion>4.0Cm Tc,5101140601,CDM,510,RC,11406,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Excision B9+Marg 2.1-3 Tc,5101142301,CDM,510,RC,11423,HCPCS,,,facility,both,,,,2040,1530,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Excision B9+Marg 2.1-3 Tc,5101142301,CDM,510,RC,11423,HCPCS,,,facility,both,,,,2040,1530,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Excision B9+Marg 2.1-3 Tc,5101142301,CDM,510,RC,11423,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc B9 Lesion 3.1-4Cm Snhfg,5101142401,CDM,510,RC,11424,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Face-Mm B9+Marg 0.5 Cm/<Tc,5101144001,CDM,510,RC,11440,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Face-Mm B9+Marg 0.6-1Cm Tc,5101144101,CDM,510,RC,11441,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Face-Mm B9+Marg 1.1-2Cm Tc,5101144201,CDM,510,RC,11442,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Face-Mm B9+Marg 2.1-3 Cm,5101144301,CDM,510,RC,11443,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Tr-Ext Mal+Marg 0.5Cm/< Tc,5101160001,CDM,510,RC,11600,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Excision Malignant Lesion Tc,5101160101,CDM,510,RC,11601,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Tr-Ext Mal+Marg 1.1-2Cm Tc,5101160201,CDM,510,RC,11602,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Tr-Ext Mal+Marg 3.1-4Cm Tc,5101160401,CDM,510,RC,11604,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Tr-Ext Mal+Marg >4 Cm Tc,5101160601,CDM,510,RC,11606,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc S/N/H/F/G Mal+Mrg 0.6-1 Tc,5101162101,CDM,510,RC,11621,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Remove Mal Lesion 1.1-2 Tc,5101162201,CDM,510,RC,11622,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc S/N/H/F/G Mal+Mrg 2.1-3,5101162301,CDM,510,RC,11623,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc S/N/H/F/G Mal+Mrg >4 Cm,5101162601,CDM,510,RC,11626,HCPCS,,,facility,both,,,,5447,4085.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc S/N/H/F/G Mal+Mrg >4 Cm,5101162601,CDM,510,RC,11626,HCPCS,,,facility,both,,,,2484,1863,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc F/E/E/N/L Mal+Mrg 0.6-1 Tc,5101164101,CDM,510,RC,11641,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc F/E/E/N/L Mal+Mrg 1.1-2 Tc,5101164201,CDM,510,RC,11642,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Removal Skin Lesion 2.1-3 Tc,5101164301,CDM,510,RC,11643,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Fac-Mm Malig+Marg 3.1-4,5101164401,CDM,510,RC,11644,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Inject Skin Lesions Up To And Including 7 Lesions,5101190001,CDM,510,RC,11900,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Inject Skin Lesions >7,5101190101,CDM,510,RC,11901,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Tis Trnfr S/A/L 10.1-30 Sqcm,5101402101,CDM,510,RC,14021,HCPCS,,,facility,both,,,,2064,1548,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tis Trnfr S/A/L 10.1-30 Sqcm,5101402101,CDM,510,RC,14021,HCPCS,,,facility,both,,,,2064,1548,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Skin Tissue Rearrangement Tc,5101404101,CDM,510,RC,14041,HCPCS,,,facility,both,,,,2064,1548,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Skin Tissue Rearrangement,5101430101,CDM,510,RC,14301,HCPCS,,,facility,both,,,,3689,2766.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Skin Tissue Rearrangement,5101430101,CDM,510,RC,14301,HCPCS,,,facility,both,,,,4242,3181.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Island Pedicle Flap Graft,5101574001,CDM,510,RC,15740,HCPCS,,,facility,both,,,,2064,1548,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Destruct Premalg Lesion Tc,5101700001,CDM,510,RC,17000,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Destruct Premalg Les 2-14 Tc,5101700301,CDM,510,RC,17003,HCPCS,,,facility,both,,,,2,1.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Destroy Premal Lesions 15/> Tc,5101700401,CDM,510,RC,17004,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Destruction Of Skin Lesions Tc,5101726001,CDM,510,RC,17260,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Destruction Mal Lesion Trunk, Arm, Leg 0.6-1.0 Cm",5101726101,CDM,510,RC,17261,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Destruction Mal Lesion Trunk, Arm, Leg 1.1-2.0Cm",5101726201,CDM,510,RC,17262,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Destruct Skin Lesions 3.1-4Cm,5101726401,CDM,510,RC,17264,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Destruction Malignant Lesion Scalp, Neck, Hands, Feet, Genitalia 1.1-2.0Cm",5101727201,CDM,510,RC,17272,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Destruction Mal Lesion Face, Ears, Eyelids, Nose, Lips, Mouth 0.6-1.0Cm",5101728101,CDM,510,RC,17281,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Destruction Mal Lesion Face, Ears, Eyelids, Nose, Lips, Mouth 1.1-2.0Cm",5101728201,CDM,510,RC,17282,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Biopsy Of Breast Open,5101910101,CDM,510,RC,19101,HCPCS,,,facility,both,,,,3309,2481.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Inj Dupuytren Cord W/Enzyme,5102052701,CDM,510,RC,20527,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Face Les Sc <2 Cm Tc,5102101101,CDM,510,RC,21011,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Face Les Sbq 2 Cm,5102101201,CDM,510,RC,21012,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Neck Les Sc < 3 Cm Tc,5102155501,CDM,510,RC,21555,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Exc Neck Les Sc < 3 Cm Tc,5102155501,CDM,510,RC,21555,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Back Les Sc < 3 Cm Tc,5102193001,CDM,510,RC,21930,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Back Tum Deep 5 Cm/>,5102193301,CDM,510,RC,21933,HCPCS,,,facility,both,,,,2857,2142.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Abd Les Sc < 3 Cm Tc,5102290201,CDM,510,RC,22902,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Clavicle Fracture,5102350001,CDM,510,RC,23500,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Arm/Elbow Les Sc 3 Cm/>,5102407101,CDM,510,RC,24071,HCPCS,,,facility,both,,,,2481,1860.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Exc Arm/Elbow Les Sc 3 Cm/>,5102407101,CDM,510,RC,24071,HCPCS,,,facility,both,,,,2484,1863,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Clsd Tx Humeral Shaft Fracture W/O Manipulation,5102450001,CDM,510,RC,24500,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Cltx Sprcndylr, Transcndylr Humeral Fx With Or Without Manj",5102453001,CDM,510,RC,24530,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Radius Fracture,5102465001,CDM,510,RC,24650,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Fracture Of Ulna,5102553001,CDM,510,RC,25530,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Fx Radius/Ulna Dis W/O,5102560001,CDM,510,RC,25600,HCPCS,,,facility,both,,,,527,395.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Treat Fx Radius/Ulna Dis W/O,5102560001,CDM,510,RC,25600,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Wrist Bone Fracture,5102562201,CDM,510,RC,25622,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Wrist Bone Fracture Tc,5102563001,CDM,510,RC,25630,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Treat Wrist Bone Fracture Tc,5102563001,CDM,510,RC,25630,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Manipulate Palm Cord Post Inj,5102634101,CDM,510,RC,26341,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Metacarpal Fracture,5102660001,CDM,510,RC,26600,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Hip Pelvis Les Sc 3 Cm/>,5102704301,CDM,510,RC,27043,HCPCS,,,facility,both,,,,2484,1863,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Cltx Medial Ankle Fx W/O Manip,5102776001,CDM,510,RC,27760,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Cltx Post Ankle Fx,5102776701,CDM,510,RC,27767,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Closed Tx Bimalleolar Ankle Fracture Without Manj,5102780801,CDM,510,RC,27808,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Closd Tx Bimalleolar Ankle Fx W Manipulation,5102781001,CDM,510,RC,27810,HCPCS,,,facility,both,,,,1460,1095,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 SUSP 7.5 ML BOTTLE,51028,CDM,250,RC,61314064175,NDC,,,facility,both,7.5,ML,,212.65,159.49,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Nasal/Sinus Endoscopy Surg Tc,5103123701,CDM,510,RC,31237,HCPCS,,,facility,both,,,,1568,1176,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Nasal/Sinus Endoscopy Surg Tc,5103123701_50,CDM,510,RC,31237,HCPCS,,,facility,both,,,50,2352,1764,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Biopsy Of Lip Tc,5104049001,CDM,510,RC,40490,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Partial Excision Of Lip Tc,5104052001,CDM,510,RC,40520,HCPCS,,,facility,both,,,,2866,2149.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Excision Of Mouth Lesion Tc,5104081001,CDM,510,RC,40810,HCPCS,,,facility,both,,,,2866,2149.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Excise/Repair Mouth Lesion Tc,5104081201,CDM,510,RC,40812,HCPCS,,,facility,both,,,,1418,1063.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Biopsy Of Tongue Tc,5104110001,CDM,510,RC,41100,HCPCS,,,facility,both,,,,474,355.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Biopsy Of Floor Of Mouth,5104110801,CDM,510,RC,41108,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Excision Of Tongue Lesion,5104111201,CDM,510,RC,41112,HCPCS,,,facility,both,,,,2866,2149.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Excision Of Gum Lesion Simple,5104182601,CDM,510,RC,41826,HCPCS,,,facility,both,,,,2866,2149.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Biopsy Roof Of Mouth Tc,5104210001,CDM,510,RC,42100,HCPCS,,,facility,both,,,,1418,1063.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Biopsy Of Throat Tc,5104280001,CDM,510,RC,42800,HCPCS,,,facility,both,,,,1418,1063.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Removal Of Anal Tags Tc,5104623001,CDM,510,RC,46230,HCPCS,,,facility,both,,,,2560,1920,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc Removal Of Anal Tags Tc,5104623001,CDM,510,RC,46230,HCPCS,,,facility,both,,,,2560,1920,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Removal Of Hemorrhoid Clot,5104632001,CDM,510,RC,46320,HCPCS,,,facility,both,,,,2615,1961.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Removal Of Hemorrhoid Clot,5104632001,CDM,510,RC,46320,HCPCS,,,facility,both,,,,1087,815.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Biopsy Of Cervix Tc,5105750001,CDM,510,RC,57500,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Inj Anes Agent Occipital Nerve,5106440501,CDM,510,RC,64405,HCPCS,,,facility,both,,,,876,657,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Inj Anes Agent Occipital Nerve,5106440501,CDM,510,RC,64405,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Injection(S), Anesthetic Agent(S) And/Or Steroid, Ilioinguinal, Iliohypogastric Nerves",5106442501,CDM,510,RC,64425,HCPCS,,,facility,both,,,,666,499.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Chemodnrvtj Musc Musc Innervated Facial Nrv Unil,5106461201,CDM,510,RC,64612,HCPCS,,,facility,both,,,,264,198,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Chemodervate Facial/Trigem/Cerv Musc Migraine,5106461501,CDM,510,RC,64615,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Chemodenervation Muscle Neck Unilat For Dystonia,5106461601,CDM,510,RC,64616,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Chemodenervation One Extremity 1-4 Muscle,5106464201,CDM,510,RC,64642,HCPCS,,,facility,both,,,,666,499.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Chemodenervation 1 Extremity Ea Addl 1-4 Muscle,5106464301,CDM,510,RC,64643,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Chemodenervation 1 Extremity 5 Or More Muscles,5106464401,CDM,510,RC,64644,HCPCS,,,facility,both,,,,666,499.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Chemodenerv Trunk Musc 1-5 Tc,5106464601,CDM,510,RC,64646,HCPCS,,,facility,both,,,,666,499.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Biopsy External Ear Canal Tc,5106910501,CDM,510,RC,69105,HCPCS,,,facility,both,,,,1418,1063.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Remove Ear Canal Lesion(S) Tc,5106914501,CDM,510,RC,69145,HCPCS,,,facility,both,,,,2484,1863,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Clean Out Mastoid Cavity Tc,5106922001,CDM,510,RC,69220,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Create Eardrum Opening Tc,5106943301,CDM,510,RC,69433,HCPCS,,,facility,both,,,,474,355.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Incise Inner Ear Tc,5106980101,CDM,510,RC,69801,HCPCS,,,facility,both,,,,1631,1223.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Ther/Proph/Diag Inj Iv Push,5109637401,CDM,510,RC,96374,HCPCS,,,facility,both,,,,236,177,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Osteopath Treat 3-4 Regions,5109892601,CDM,510,RC,98926,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Osteopath Manj 5-6 Regions,5109892701,CDM,510,RC,98927,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Care Mgmt Svc Bhvl Hlth 20 Min,5109948401,CDM,510,RC,99484,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Cmplx Chron Care W/O Pt Vsit,5109948701,CDM,510,RC,99487,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Chron Care Mgmt Srvc 20 Min,5109949001,CDM,510,RC,99490,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc 1St Psyc Collab Care Mgt 70Min,5109949201,CDM,510,RC,99492,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc  Sbsq Psyc Collab Care 1St 60M,5109949301,CDM,510,RC,99493,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc 1St/Sbsq Psyc Collab Care,5109949401,CDM,510,RC,99494,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Tran Care Mgmt With Comm Within 2 Bus. Days Of D/C And At Least Moderate Med Dec Face/Face Visit,",5109949501,CDM,510,RC,99495,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Tran Care Mgmt With Comm Within 2 Bus. Days Of D/C And At Least High Med Dec Face/Face Visit,W/In",5109949601,CDM,510,RC,99496,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Initial Preventive Exam Tc,510G040201,CDM,510,RC,G0402,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Annual Wellness Visit, Includes A Personalized Prevention Plan Of Service (Pps), Subsequent Visit",510G043901,CDM,510,RC,G0439,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Init/Sub Psych Care M 1St 30,510G221401,CDM,510,RC,G2214,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
CYCLOSPORINE 0.05 % EMUL,51110,CDM,250,RC,MHS0.1ML,HCPCS,23916330,NDC,facility,both,0.1,ML,,25.3,18.97,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG TABS,51400,CDM,250,RC,78040134,NDC,,,facility,both,4,UN,,391.66,293.75,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG TABS,51400,CDM,250,RC,47335047281,NDC,,,facility,both,4,UN,,25.85,19.39,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG TABS,51400,CDM,250,RC,47335047281,NDC,,,facility,both,1,UN,,52.1,39.08,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SUBL,51404,CDM,636,RC,J0571,HCPCS,62756045983,NDC,facility,both,1,ME,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SUBL,51404,CDM,636,RC,J0571,HCPCS,60687048121,NDC,facility,both,1,ME,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SUBL,51405,CDM,636,RC,J0571,HCPCS,54017713,NDC,facility,both,1,ME,,1.01,0.76,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,80681002200,NDC,,,facility,both,5,UN,,1.39,1.04,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,37000040514,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,80681002200,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,37000040514,NDC,,,facility,both,2,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,37000040514,NDC,,,facility,both,5,UN,,1.79,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,80681002200,NDC,,,facility,both,2,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,37000040514,NDC,,,facility,both,1.04,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,37000040514,NDC,,,facility,both,6,UN,,1.53,1.15,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,80681002200,NDC,,,facility,both,3,UN,,2.2,1.65,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM 0.52 GM CAPS,51406,CDM,250,RC,37000040514,NDC,,,facility,both,3,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT 80 MG CAPS,51408,CDM,636,RC,J8501,HCPCS,68462058458,NDC,facility,both,5,ME,,11.32,8.49,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 3.9 MG/24 HRS PTTW,51414,CDM,250,RC,23615301,NDC,,,facility,both,1,UN,,153,114.75,,,,,,,,,,Gross Charge Type: Pharmacy
CRANBERRY 450 MG TABS,51425,CDM,250,RC,57896084501,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
CRANBERRY 450 MG TABS,51425,CDM,250,RC,57896084501,NDC,,,facility,both,6,UN,,1.2,0.9,,,,,,,,,,Gross Charge Type: Pharmacy
CRANBERRY 450 MG TABS,51425,CDM,250,RC,57896084501,NDC,,,facility,both,2,UN,,3.2,2.4,,,,,,,,,,Gross Charge Type: Pharmacy
ZAFIRLUKAST 20 MG TABS,5152,CDM,250,RC,55111062660,NDC,,,facility,both,1,UN,,10.25,7.69,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG TBDP,51548,CDM,250,RC,62332036706,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG TBDP,51548,CDM,250,RC,62332036706,NDC,,,facility,both,2,UN,,4.1,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG TBDP,51548,CDM,250,RC,62332036706,NDC,,,facility,both,0.5,UN,,5.95,4.46,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG TBDP,51548,CDM,250,RC,49884030902,NDC,,,facility,both,2,UN,,4.75,3.56,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG TBDP,51548,CDM,250,RC,49884030902,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG TBDP,51548,CDM,250,RC,49884030902,NDC,,,facility,both,1,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 0.8 MG/ML CONC 5 ML VIAL,51560,CDM,636,RC,J3489,HCPCS,54288010001,NDC,facility,both,1,ME,,26.76,20.07,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 0.8 MG/ML CONC 5 ML VIAL,51560,CDM,636,RC,J3489,HCPCS,72603019801,NDC,facility,both,1,ME,,19.96,14.97,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 0.8 MG/ML CONC 5 ML VIAL,51560,CDM,636,RC,J3489,HCPCS,67457039054,NDC,facility,both,1,ME,,34.23,25.67,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 0.8 MG/ML CONC 5 ML VIAL,51560,CDM,636,RC,J3489,HCPCS,55111068507,NDC,facility,both,1,ME,,20.64,15.48,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 0.5 MG TBDP,51607,CDM,250,RC,59746001032,NDC,,,facility,both,2,UN,,5.72,4.29,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 0.5 MG TBDP,51607,CDM,250,RC,49884031155,NDC,,,facility,both,1,UN,,14.9,11.18,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 0.5 MG TBDP,51607,CDM,250,RC,49884031155,NDC,,,facility,both,2,UN,,10.55,7.91,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 0.5 MG TBDP,51607,CDM,250,RC,59746001032,NDC,,,facility,both,1,UN,,9.56,7.17,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,59746002022,NDC,,,facility,both,1,UN,,9.15,6.87,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,59746002022,NDC,,,facility,both,3,UN,,4.53,3.4,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,59746002022,NDC,,,facility,both,4,UN,,3.86,2.9,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,59746002022,NDC,,,facility,both,1.5,UN,,5.38,4.03,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,49884031591,NDC,,,facility,both,3,UN,,9.95,7.46,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,49884031555,NDC,,,facility,both,2,UN,,9.12,6.84,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,49884031591,NDC,,,facility,both,1,UN,,16,12,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,59746002022,NDC,,,facility,both,2,UN,,5.88,4.41,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,49884031555,NDC,,,facility,both,1,UN,,13.3,9.98,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 1 MG TBDP,51608,CDM,250,RC,49884031555,NDC,,,facility,both,3,UN,,7.62,5.71,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 2 MG TBDP,51609,CDM,250,RC,59746003022,NDC,,,facility,both,2,UN,,5.74,4.31,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE TABLET DISPERSIBLE 2 MG TBDP,51609,CDM,250,RC,59746003022,NDC,,,facility,both,1,UN,,6.5,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 0.5 % SOLN 3 ML BOTTLE,51620,CDM,250,RC,MHS1ML,HCPCS,60505058204,NDC,facility,both,1,ML,,43.47,32.6,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 750 MG TB24,51693,CDM,250,RC,67877041401,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN 750 MG TB24,51693,CDM,250,RC,67877041401,NDC,,,facility,both,2,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 35 MG SOLR 1 EACH VIAL,51697,CDM,636,RC,J0180,HCPCS,58468004001,NDC,facility,both,1,ME,,514.2,385.65,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL-PROPYLENE GLYCOL 0.4-0.3 % SOLN 15 ML BOTTLE,51812,CDM,250,RC,65042915,NDC,,,facility,both,15,ML,,40.65,30.49,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 4 MG PACK,51939,CDM,250,RC,27241001531,NDC,,,facility,both,1,UN,,13.8,10.35,,,,,,,,,,Gross Charge Type: Pharmacy
0.45% NACL WITH KCL 20 MEQ/L SOLUTION 20-0.45 MEQ/L-% SOLN,51962,CDM,636,RC,J3480,HCPCS,338070434,NDC,facility,both,1000,ML,,1.95,1.46,,,,,,,,,,Gross Charge Type: Pharmacy
0.45% NACL WITH KCL 20 MEQ/L SOLUTION 20-0.45 MEQ/L-% SOLN,51962,CDM,636,RC,J3480,HCPCS,338070434,NDC,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SOLR,52058,CDM,636,RC,J2357,HCPCS,50242004062,NDC,facility,both,5,ME,,98.41,73.8,,,,,,,,,,Gross Charge Type: Pharmacy
ESTROGENS CONJUGATED 0.45 MG TABS,52105,CDM,250,RC,46110181,NDC,,,facility,both,1,UN,,19.9,14.92,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBETASOL 0.05 % LOTN 59 ML BOTTLE,52115,CDM,250,RC,472040492,NDC,,,facility,both,59,ML,,367.3,275.48,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG TABS,52125,CDM,250,RC,60687024501,NDC,,,facility,both,4,UN,,4.46,3.35,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG TABS,52125,CDM,250,RC,68462026290,NDC,,,facility,both,2,UN,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG TABS,52125,CDM,250,RC,60687024501,NDC,,,facility,both,2,UN,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG TABS,52125,CDM,250,RC,68462026290,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG TABS,52125,CDM,250,RC,60687024501,NDC,,,facility,both,1,UN,,10.45,7.84,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG TABS,52125,CDM,250,RC,60687024501,NDC,,,facility,both,0.5,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG TABS,52126,CDM,250,RC,60687025601,NDC,,,facility,both,2,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG TABS,52126,CDM,250,RC,60687025601,NDC,,,facility,both,1,UN,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG TABS,52126,CDM,250,RC,16714099001,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG TABS,52126,CDM,250,RC,60687025601,NDC,,,facility,both,0.5,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG TABS,52126,CDM,250,RC,60687025601,NDC,,,facility,both,3,UN,,5.37,4.02,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,63739097310,NDC,,,facility,both,1,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,245531901,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,245531901,NDC,,,facility,both,4,UN,,2.41,1.81,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,245531901,NDC,,,facility,both,1.5,UN,,4.08,3.06,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,245531901,NDC,,,facility,both,0.5,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,63739097310,NDC,,,facility,both,2,UN,,4.8,3.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,69238106901,NDC,,,facility,both,1,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,69238106901,NDC,,,facility,both,2,UN,,4.28,3.21,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,245531901,NDC,,,facility,both,1,UN,,7.45,5.59,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ TBCR,52135,CDM,250,RC,245531901,NDC,,,facility,both,3,UN,,3.05,2.29,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,16714014201,NDC,,,facility,both,2,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,16714014201,NDC,,,facility,both,0.4,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,16714014201,NDC,,,facility,both,4,UN,,2.42,1.82,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,16714014201,NDC,,,facility,both,1,UN,,7.08,5.31,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,65862066230,NDC,,,facility,both,1,UN,,8.99,6.75,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,65862066230,NDC,,,facility,both,0.5,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,16714014201,NDC,,,facility,both,3,UN,,3.07,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,65862066230,NDC,,,facility,both,1.5,UN,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,50268008811,NDC,,,facility,both,1,UN,,16.8,12.6,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,50268008811,NDC,,,facility,both,2,UN,,12.3,9.22,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,50268008815,NDC,,,facility,both,2,UN,,12.3,9.22,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,65862066230,NDC,,,facility,both,2,UN,,5.62,4.22,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,50268008815,NDC,,,facility,both,1,UN,,16.74,12.56,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,65862066230,NDC,,,facility,both,3,UN,,3.98,2.98,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,16714014201,NDC,,,facility,both,0.5,UN,,0.75,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,65862066230,NDC,,,facility,both,4,UN,,3.64,2.73,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 5 MG TABS,52378,CDM,250,RC,50268008815,NDC,,,facility,both,1.5,UN,,10.4,7.8,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP,52516,CDM,250,RC,MHS7.5ML,HCPCS,781618667,NDC,facility,both,7.5,ML,,277.72,208.29,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,52516,CDM,250,RC,MHS7.5ML,HCPCS,43598032675,NDC,facility,both,7.5,ML,,208.71,156.54,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % SUSP 7.5 ML BOTTLE,52516,CDM,250,RC,MHS7.5ML,HCPCS,65853302,NDC,facility,both,7.5,ML,,354.77,266.08,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML SOLN,52530,CDM,250,RC,MHS1ML,HCPCS,16714035801,NDC,facility,both,1,ML,,0.67,0.5,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5ML SOLN,52531,CDM,636,RC,J2469,HCPCS,781331275,NDC,facility,both,5,ML,,7.49,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5ML SOLN 5 ML VIAL,52531,CDM,636,RC,J2469,HCPCS,781331275,NDC,facility,both,5,ML,,7.49,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,70377000612,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,60687023401,NDC,,,facility,both,1,UN,,10.25,7.69,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,70377000612,NDC,,,facility,both,2,UN,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,70377000612,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,60687023401,NDC,,,facility,both,2,UN,,6.38,4.78,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,60687023401,NDC,,,facility,both,4,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,70377000612,NDC,,,facility,both,4,UN,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,57237016890,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,57237016890,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,60687023401,NDC,,,facility,both,0.5,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 5 MG TABS,52552,CDM,250,RC,57237016890,NDC,,,facility,both,2,UN,,4.2,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 150 MG TB24,52715,CDM,250,RC,904708404,NDC,,,facility,both,3,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 150 MG TB24,52715,CDM,250,RC,16729044315,NDC,,,facility,both,1,UN,,7.03,5.27,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 150 MG TB24,52715,CDM,250,RC,904708404,NDC,,,facility,both,2,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 150 MG TB24,52715,CDM,250,RC,904708461,NDC,,,facility,both,3,UN,,6.18,4.64,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 150 MG TB24,52715,CDM,250,RC,591333119,NDC,,,facility,both,1,UN,,9.64,7.23,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 150 MG TB24,52715,CDM,250,RC,904708461,NDC,,,facility,both,1,UN,,11.65,8.74,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 150 MG TB24,52715,CDM,250,RC,16729044315,NDC,,,facility,both,2,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 150 MG TB24,52715,CDM,250,RC,904708404,NDC,,,facility,both,1,UN,,9.82,7.36,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 300 MG TB24,52716,CDM,250,RC,68180032006,NDC,,,facility,both,1,UN,,6.79,5.09,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 300 MG TB24,52716,CDM,250,RC,63739013233,NDC,,,facility,both,1,UN,,10.27,7.7,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN SOLR 1 EACH VIAL,52885,CDM,636,RC,J0877,HCPCS,409012201,NDC,facility,both,1,ME,,0.47,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN SOLR 1 EACH VIAL,52885,CDM,636,RC,J0878,HCPCS,409012201,NDC,facility,both,1,ME,,0.48,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN SOLR 1 EACH VIAL,52885,CDM,636,RC,J0878,HCPCS,71288001615,NDC,facility,both,1,ME,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN SOLR 1 EACH VIAL,52885,CDM,636,RC,J0878,HCPCS,60505622904,NDC,facility,both,1,ME,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN SOLR 1 EACH VIAL,52885,CDM,636,RC,J0878,HCPCS,43598041311,NDC,facility,both,1,ME,,0.26,0.2,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN SOLR 1 EACH VIAL,52885,CDM,636,RC,J0878,HCPCS,16714089201,NDC,facility,both,1,ME,,0.16,0.12,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN SOLR 1 EACH VIAL,52885,CDM,636,RC,J0878,HCPCS,143937801,NDC,facility,both,1,ME,,0.24,0.18,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE 25 MG TABS,53141,CDM,250,RC,16729029310,NDC,,,facility,both,1,UN,,10.35,7.76,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE 25 MG TABS,53141,CDM,250,RC,16729029310,NDC,,,facility,both,0.5,UN,,8.3,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE 25 MG TABS,53141,CDM,250,RC,16729029310,NDC,,,facility,both,2,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
TADALAFIL 20 MG TABS,53143,CDM,250,RC,16714007701,NDC,,,facility,both,2,UN,,5.98,4.48,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG CAPS,53251,CDM,250,RC,77333080025,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG CAPS,53251,CDM,250,RC,77333080050,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG CAPS,53251,CDM,250,RC,4142000007,NDC,,,facility,both,1,UN,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % LIQD,53346,CDM,250,RC,78112001104,NDC,,,facility,both,1,ML,,3.5,2.62,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % LIQD 177 ML BOTTLE,53346,CDM,250,RC,78112001103,NDC,,,facility,both,1,ML,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % LIQD 177 ML BOTTLE,53346,CDM,250,RC,49348099136,NDC,,,facility,both,1,ML,,3.2,2.4,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 25 MG CAPS,53348,CDM,250,RC,68462012801,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 25 MG CAPS,53348,CDM,250,RC,68462012801,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 5 MG TABS,53355,CDM,250,RC,904650561,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 5 MG TABS,53355,CDM,250,RC,904650506,NDC,,,facility,both,1,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 5 MG TABS,53355,CDM,250,RC,904650561,NDC,,,facility,both,4,UN,,2.8,2.1,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 5 MG TABS,53355,CDM,250,RC,904650561,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 100 MG TB12,53360,CDM,250,RC,68084069701,NDC,,,facility,both,2,UN,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 100 MG TB12,53360,CDM,250,RC,591354060,NDC,,,facility,both,2,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 100 MG TB12,53360,CDM,250,RC,591354060,NDC,,,facility,both,1,UN,,7.55,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION 100 MG TB12,53360,CDM,250,RC,68084069701,NDC,,,facility,both,1,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G PACK,53415,CDM,250,RC,245003660,NDC,,,facility,both,1,UN,,10.85,8.14,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTHERIA TOXOID TD >/= 7 YEARS 2-2 LF/0.5 ML SUSP,53437,CDM,636,RC,90714,HCPCS,13533013101,NDC,facility,both,0.5,ML,,82.75,62.06,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTHERIA TOXOID TD >/= 7 YEARS 2-2 LF/0.5 ML SUSP,53437,CDM,636,RC,90714,HCPCS,49281021515,NDC,facility,both,0.5,ML,,112.9,84.68,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTHERIA TOXOIDS TD 2-2 LF/0.5ML IM SUSP,53437,CDM,13533013101,NDC,,,,,facility,both,0.5,ML,,29.13,21.85,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTHERIA TOXOIDS TD 2-2 LF/0.5ML IM SUSP,53437,CDM,49281021515,NDC,,,,,facility,both,0.5,ML,,41.1,30.82,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT SOLUTION PLUS SOLN,53517,CDM,250,RC,MHS100ML,HCPCS,65080050,NDC,facility,both,100,ML,,22.28,16.71,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT SOLUTION SOLN,53518,CDM,250,RC,MHS10ML,HCPCS,65079515,NDC,facility,both,100,ML,,31.17,23.38,,,,,,,,,,Gross Charge Type: Pharmacy
KETOCONAZOLE 2 % SHAM 120 ML BOTTLE,53537,CDM,250,RC,MHS1ML,HCPCS,45802046564,NDC,facility,both,1,ML,,0.51,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,43547028010,NDC,,,facility,both,2,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,43547028010,NDC,,,facility,both,3,UN,,2.57,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,65862037301,NDC,,,facility,both,1.5,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,43547028010,NDC,,,facility,both,1.5,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,65862037301,NDC,,,facility,both,1,UN,,7.43,5.57,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,43547028010,NDC,,,facility,both,0.5,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,65862037301,NDC,,,facility,both,4,UN,,2.44,1.83,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,43547028010,NDC,,,facility,both,4,UN,,2.06,1.55,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,43547028010,NDC,,,facility,both,1,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 5 MG TABS,53546,CDM,250,RC,65862037301,NDC,,,facility,both,2,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,51079025520,NDC,,,facility,both,0.25,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,51079025520,NDC,,,facility,both,1.5,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,378001801,NDC,,,facility,both,0.25,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,378001801,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,51079025520,NDC,,,facility,both,2.5,UN,,2.35,1.76,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,FAMRXNC,HCPCS,51079025520,NDC,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,51079025520,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,51079025520,NDC,,,facility,both,4,UN,,1.91,1.43,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,378001801,NDC,,,facility,both,3,UN,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,51079025520,NDC,,,facility,both,3,UN,,2.42,1.81,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,378001801,NDC,,,facility,both,4,UN,,1.81,1.36,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,378001801,NDC,,,facility,both,1,UN,,6.24,4.68,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,51079025520,NDC,,,facility,both,1,UN,,6.41,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,378001801,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,65862006201,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,62332011231,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS,53547,CDM,250,RC,51079025520,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TABS 1 TABLET BLISTER,53547,CDM,250,RC,378001801,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5ML SOLR,53550,CDM,250,RC,MHS1ML,HCPCS,9076004,NDC,facility,both,1,ML,,0.74,0.55,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5ML SOLR,53550,CDM,250,RC,MHS1ML,HCPCS,16714048301,NDC,facility,both,1,ML,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 225 MG CP12,53719,CDM,250,RC,16714082501,NDC,,,facility,both,1,UN,,11.65,8.74,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 325 MG CP12,53720,CDM,250,RC,16714082601,NDC,,,facility,both,1,UN,,12.6,9.45,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG SOLR 1 EACH VIAL,53804,CDM,636,RC,J9305,HCPCS,2762301,NDC,facility,both,10,ME,,212.33,159.25,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 2 MG/ML SOLN 100 ML VIAL,53900,CDM,636,RC,J9055,HCPCS,66733095823,NDC,facility,both,10,ME,,214.68,161.01,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 2 MG/ML SOLN 50 ML VIAL,53900,CDM,636,RC,J9055,HCPCS,66733094823,NDC,facility,both,10,ME,,240.21,180.15,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN FLUSH 10 UNITS/ML SOLN,53905,CDM,636,RC,J1642,HCPCS,64253022235,NDC,facility,both,10,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 2.5 MG TB24,53936,CDM,250,RC,68084029521,NDC,,,facility,both,1,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TB24,53937,CDM,250,RC,16714089501,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TB24,53937,CDM,250,RC,68084011101,NDC,,,facility,both,4,UN,,3.14,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TB24,53937,CDM,250,RC,68084011101,NDC,,,facility,both,3,UN,,3.78,2.84,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TB24,53937,CDM,250,RC,68084011101,NDC,,,facility,both,2,UN,,5.08,3.81,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TB24,53937,CDM,250,RC,16714089501,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 5 MG TB24,53937,CDM,250,RC,68084011101,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG TB12,53959,CDM,250,RC,904671839,NDC,,,facility,both,2,UN,,5.08,3.81,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG TB12,53959,CDM,250,RC,63739006702,NDC,,,facility,both,1,UN,,9,6.75,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG TB12,53959,CDM,250,RC,63739006702,NDC,,,facility,both,2,UN,,5.18,3.88,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG TB12,53959,CDM,250,RC,904671839,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG TB12,53959,CDM,250,RC,63824000815,NDC,,,facility,both,1,UN,,7.95,5.96,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG TB12,53959,CDM,250,RC,68084057201,NDC,,,facility,both,1,UN,,9.2,6.9,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TB24,53963,CDM,250,RC,63739054833,NDC,,,facility,both,2,UN,,9.08,6.81,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TB24,53963,CDM,250,RC,904657061,NDC,,,facility,both,2,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TB24,53963,CDM,250,RC,63739054833,NDC,,,facility,both,3,UN,,7.58,5.69,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TB24,53963,CDM,250,RC,904657061,NDC,,,facility,both,3,UN,,5.89,4.42,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TB24,53963,CDM,250,RC,68084048011,NDC,,,facility,both,3,UN,,7.43,5.57,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TB24,53963,CDM,250,RC,68084048011,NDC,,,facility,both,2,UN,,8.92,6.69,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TB24,53963,CDM,250,RC,904657061,NDC,,,facility,both,1,UN,,10.93,8.2,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN 5 MG TB24,53963,CDM,250,RC,63739054833,NDC,,,facility,both,1,UN,,13.3,9.98,,,,,,,,,,Gross Charge Type: Pharmacy
ALFUZOSIN 10 MG TB24,53966,CDM,250,RC,47335095688,NDC,,,facility,both,1,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
ALFUZOSIN 10 MG TB24,53966,CDM,250,RC,29300015501,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG CP12,53979,CDM,250,RC,29033003001,NDC,,,facility,both,1,UN,,9,6.75,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG CP12,53979,CDM,250,RC,23155078701,NDC,,,facility,both,1,UN,,9.15,6.86,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 90 MG TB24,53990,CDM,250,RC,50742062201,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG TBEC,54057,CDM,636,RC,J7518,HCPCS,68084091825,NDC,facility,both,180,ME,,9.44,7.08,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG TBEC,54057,CDM,636,RC,J7518,HCPCS,67877042712,NDC,facility,both,180,ME,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG TABS,54095,CDM,250,RC,16729044010,NDC,,,facility,both,2,UN,,4.92,3.69,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG TABS,54095,CDM,250,RC,16729044010,NDC,,,facility,both,6,UN,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG TABS,54095,CDM,250,RC,16729044010,NDC,,,facility,both,3,UN,,3.63,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG TABS,54095,CDM,250,RC,16729044010,NDC,,,facility,both,1,UN,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG TABS,54095,CDM,250,RC,67877050330,NDC,,,facility,both,3,UN,,12.45,9.34,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG TABS,54095,CDM,250,RC,67877050330,NDC,,,facility,both,1,UN,,18.75,14.06,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG TABS,54095,CDM,250,RC,67877050330,NDC,,,facility,both,6,UN,,10.69,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG TABS,54095,CDM,250,RC,16729044010,NDC,,,facility,both,4,UN,,2.99,2.24,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG TABS,54095,CDM,250,RC,67877050330,NDC,,,facility,both,2,UN,,14.15,10.61,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 40 MG/ML SUSR,54098,CDM,250,RC,MHS1ML,HCPCS,59762093503,NDC,facility,both,1,ML,,13.21,9.91,,,,,,,,,,Gross Charge Type: Pharmacy
C Nm Tc-99M Exametazime Per Dose Ceretec - A9521,5413149,CDM,343,RC,A9521,HCPCS,,,facility,both,,,,7971,5978.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Ceretec: 5 Vial In 1 Tray (17156-022-05)  / 5 Ml In 1 Vial,5413149_17156002205,CDM,343,RC,A9521,HCPCS,17156002205,NDC,facility,both,1,EA,,7971,5978.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Ceretec: 1 KIT in 1 CARTON (17156-023-05)  *  5 VIAL in 1 TRAY / 1 mL in 1 VIAL *  5 VIAL in 1 TRAY / 4.5 mL in 1 VIAL *  5 VIAL in 1 TRAY (17156-022-05)  / 5 mL in 1 VIAL,5413149_17156002305,CDM,343,RC,A9521,HCPCS,17156002305,NDC,facility,both,1,EA,,7520,5640,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm In-111 Pentetreotide Dx Per Dose - A9572,5413157,CDM,343,RC,A9572,HCPCS,,,facility,both,,,,8884,6663,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Indium Dtpa In 111: 1.5 Ml In 1 Vial, Glass (17156-251-08)",5413157_17156025108,CDM,343,RC,A9572,HCPCS,17156025108,NDC,facility,both,1,EA,,8884,6663,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Tc-99M Sestamibi Dx Per Study Dose - A9500,5413161,CDM,343,RC,A9500,HCPCS,,,facility,both,,,,153,114.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Tc-99M Sestamibi Dx Per Study Dose - A9500,5413161,CDM,343,RC,A9500,HCPCS,,,facility,both,,,,177,132.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"TechneScan HDP: 5 VIAL in 1 CELLO PACK (0019-9091-20)  / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL",5413161_00019909120,CDM,343,RC,A9500,HCPCS,00019909120,NDC,facility,both,1,EA,,177,132.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
NDC Description Not Available,5413161_000199092BO,CDM,343,RC,A9500,HCPCS,000199092BO,NDC,facility,both,1,EA,,177,132.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Ultra-TechneKow: 1 INJECTION, SOLUTION in 1 CARTON (0019-9891-11)",5413161_00019989111,CDM,343,RC,A9500,HCPCS,00019989111,NDC,facility,both,1,EA,,177,132.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Kit For The Preparation Of Technetium Tc99M Sestamibi: 20 Vial In 1 Carton (65857-500-20)  / 5 Ml In 1 Vial,5413161_65857050020,CDM,343,RC,A9500,HCPCS,65857050020,NDC,facility,both,1,EA,,171.66,128.74,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Tc-99M Medronate Dx Uc To 30 Mci - A9503,5413163,CDM,343,RC,A9503,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Kit For The Preparation Of Technetium Tc 99M Medronate: 5 Vial, Multi-Dose In 1 Kit (45567-0040-1)  / 10 Ml In 1 Vial, Multi-Dose",5413163_45567004001,CDM,343,RC,A9503,HCPCS,45567004001,NDC,facility,both,1,EA,,110.78,83.08,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Kit For The Preparation Of Technetium Tc 99M Medronate: 30 Vial, Multi-Dose In 1 Kit (45567-0040-2)  / 10 Ml In 1 Vial, Multi-Dose",5413163_45567004002,CDM,343,RC,A9503,HCPCS,45567004002,NDC,facility,both,1,EA,,111.05,83.29,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Kit For The Preparation Of Technetium Tc 99M Mebrofenin: 5 Vial, Multi-Dose In 1 Kit (45567-0455-1)  / 10 Ml In 1 Vial, Multi-Dose",5413163_45567045501,CDM,343,RC,A9503,HCPCS,45567045501,NDC,facility,both,1,EA,,108,81,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
NDC Description Not Available,5413163_65857010103,CDM,343,RC,A9503,HCPCS,65857010103,NDC,facility,both,1,EA,,108,81,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Tl-201 Thallous Chlorid Dx Per Mci - A9505,5413164,CDM,343,RC,A9505,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Tl-201 Thallous Chlorid Dx Per Mci - A9505,5413164,CDM,343,RC,A9505,HCPCS,,,facility,both,,,,44,33,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Nm Tc-99M Pertechnetate Dx Per Millicurie - A9512,5413165,CDM,343,RC,A9512,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Ultra-TechneKow: 1 INJECTION, SOLUTION in 1 CARTON (0019-9891-11)",5413165_00019989111,CDM,343,RC,A9512,HCPCS,00019989111,NDC,facility,both,1,EA,,62.36,46.77,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm I-123 Sodium Iodide Cap Per 100Uci - A9516,5413166,CDM,343,RC,A9516,HCPCS,,,facility,both,,,,161,120.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"SODIUM IODIDE I 123: 1 BOTTLE in 1 CAN (0019-9601-10)  / 1 CAPSULE, GELATIN COATED in 1 BOTTLE",5413166_00019960110,CDM,343,RC,A9516,HCPCS,00019960110,NDC,facility,both,1,EA,,153.8,115.35,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"SODIUM IODIDE I 123: 1 BOTTLE in 1 CAN (0019-9602-20)  / 1 CAPSULE, GELATIN COATED in 1 BOTTLE",5413166_00019960220,CDM,343,RC,A9516,HCPCS,00019960220,NDC,facility,both,1,EA,,155.6,116.7,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Sodium Iodide I 123: 1 Vial, Plastic In 1 Can (48815-1001-1)  / 1 Capsule, Gelatin Coated In 1 Vial, Plastic",5413166_48815100101,CDM,343,RC,A9516,HCPCS,48815100101,NDC,facility,both,1,EA,,155.6,116.7,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Sodium Iodide I 123: 1 Vial, Plastic In 1 Can (48815-1002-1)  / 1 Capsule, Gelatin Coated In 1 Vial, Plastic",5413166_48815100201,CDM,343,RC,A9516,HCPCS,48815100201,NDC,facility,both,1,EA,,161,120.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm I-131 Cap Tx Per Mci - A9517,5413167,CDM,344,RC,A9517,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
SODIUM IODIDE I 131: 1 CAPSULE in 1 CAN (0019-9452-01)  / 1 mL in 1 CAPSULE,5413167_00019945201,CDM,344,RC,A9517,HCPCS,00019945201,NDC,facility,both,1,EA,,119.72,89.79,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
NDC Description Not Available,5413167_00091N452F1,CDM,344,RC,A9517,HCPCS,00091N452F1,NDC,facility,both,1,EA,,118,88.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hicon: 1 Vial In 1 Kit (65174-880-25)  / .25 Ml In 1 Vial,5413167_65174088025,CDM,344,RC,A9517,HCPCS,65174088025,NDC,facility,both,1,EA,,123.18,92.38,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm I-131 Cap Dx Per Mci - A9528,5413168,CDM,343,RC,A9528,HCPCS,,,facility,both,,,,234,175.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
SODIUM IODIDE I 131: 1 CAPSULE in 1 CAN (0019-9452-01)  / 1 mL in 1 CAPSULE,5413168_00019945201,CDM,343,RC,A9528,HCPCS,00019945201,NDC,facility,both,1,EA,,221,165.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hicon: 1 Vial In 1 Kit (65174-880-25)  / .25 Ml In 1 Vial,5413168_65174088025,CDM,343,RC,A9528,HCPCS,65174088025,NDC,facility,both,1,EA,,221,165.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Tc-99M Mebrofenin Dx Up To 15 Mci - A9537,5413169,CDM,343,RC,A9537,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Kit For The Preparation Of Technetium Tc 99M Mebrofenin: 5 Vial, Multi-Dose In 1 Kit (45567-0455-1)  / 10 Ml In 1 Vial, Multi-Dose",5413169_45567045501,CDM,343,RC,A9537,HCPCS,45567045501,NDC,facility,both,1,EA,,91.73,68.8,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Tc-99M Pyrophoshate Dx Up To 25 Mci,5413170,CDM,343,RC,A9538,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Kit For The Preparation Of Technetium Tc99M Pyrophosphate: 5 Vial, Multi-Dose In 1 Kit (45567-0060-1)  / 10 Ml In 1 Vial, Multi-Dose",5413170_45567006001,CDM,343,RC,A9538,HCPCS,45567006001,NDC,facility,both,1,EA,,81,60.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Tc-99M Pentetate Dx Up To 25 Mci - A9539,5413171,CDM,343,RC,A9539,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
NDC Description Not Available,5413171_65174028805,CDM,343,RC,A9539,HCPCS,65174028805,NDC,facility,both,1,EA,,166,124.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Tc-99M Maa Dx Stdy Dose Up To 10 Mci - A9540,5413172,CDM,343,RC,A9540,HCPCS,,,facility,both,,,,345,258.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Draximage Maa: 30 Injection, Powder, For Solution In 1 Kit (65174-270-30)",5413172_65174027030,CDM,343,RC,A9540,HCPCS,65174027030,NDC,facility,both,1,EA,,333.41,250.06,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Draximage Dtpa: 30 Injection, Powder, Lyophilized, For Solution In 1 Kit (65174-288-30)",5413172_65174028830,CDM,343,RC,A9540,HCPCS,65174028830,NDC,facility,both,1,EA,,325,243.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm In-111 Pentetate Dx Per 0.5 Millicurie - A9548,5413175,CDM,343,RC,A9548,HCPCS,,,facility,both,,,,5370,4027.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Indium Dtpa In 111: 1.5 Ml In 1 Vial, Glass (17156-251-08)",5413175_17156025108,CDM,343,RC,A9548,HCPCS,17156025108,NDC,facility,both,1,EA,,5370,4027.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Pet F-18 Fdg Dx Up To 45 Mci,5413177,CDM,343,RC,A9552,HCPCS,,,facility,both,,,,1335,1001.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Fludeoxyglucose F 18: 1 Vial, Multi-Dose In 1 Can (40028-511-30)  / 30 Ml In 1 Vial, Multi-Dose",5413177_40028051130,CDM,343,RC,A9552,HCPCS,40028051130,NDC,facility,both,1,EA,,1299.51,974.63,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Kit For The Preparation Of Technetium Tc 99M Medronate: 30 Vial, Multi-Dose In 1 Kit (45567-0040-2)  / 10 Ml In 1 Vial, Multi-Dose",5413177_45567004002,CDM,343,RC,A9552,HCPCS,45567004002,NDC,facility,both,1,EA,,1335,1001.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
NDC Description Not Available,5413177_65857010103,CDM,343,RC,A9552,HCPCS,65857010103,NDC,facility,both,1,EA,,1259,944.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Detectnet: 1 Vial, Single-Use In 1 Can (69945-064-01)  / 4 Ml In 1 Vial, Single-Use",5413177_69945006401,CDM,343,RC,A9552,HCPCS,69945006401,NDC,facility,both,1,EA,,1335,1001.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Illuccix: 1 Kit In 1 Carton (74725-100-64)  *  2.5 Ml In 1 Vial, Multi-Dose (74725-102-25)  *  6.4 Ml In 1 Vial, Multi-Dose (74725-103-64)  *  1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Multi-Dose (74725-101-25)",5413177_74725010064,CDM,343,RC,A9552,HCPCS,74725010064,NDC,facility,both,1,EA,,1259,944.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Ga-67 Citrate Diagnostic Per Millicurie - A9556,5413178,CDM,343,RC,A9556,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Tc-99M Labeled Rbc Dx Up To 30 Mci - A9560,5413180,CDM,343,RC,A9560,HCPCS,,,facility,both,,,,264,198,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Tc-99M Labeled Rbc Dx Up To 30 Mci - A9560,5413180,CDM,343,RC,A9560,HCPCS,,,facility,both,,,,264,198,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"UltraTag: 5 CELLO PACK in 1 BOX (0019-9068-20)  / 1 KIT in 1 CELLO PACK *  .6 mL in 1 SYRINGE, GLASS *  1 mL in 1 SYRINGE, GLASS *  9.5 mg in 1 VIAL, GLASS",5413180_00019906820,CDM,343,RC,A9560,HCPCS,00019906820,NDC,facility,both,1,EA,,264,198,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Ultra-TechneKow: 1 INJECTION, SOLUTION in 1 CARTON (0019-9891-11)",5413180_00019989111,CDM,343,RC,A9560,HCPCS,00019989111,NDC,facility,both,1,EA,,264,198,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Kit For The Preparation Of Technetium Tc99M Pyrophosphate: 5 Vial, Multi-Dose In 1 Kit (45567-0060-1)  / 10 Ml In 1 Vial, Multi-Dose",5413180_45567006001,CDM,343,RC,A9560,HCPCS,45567006001,NDC,facility,both,1,EA,,264,198,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Tc-99M Mertiatide Dx Up To 15 Mci - A9562,5413182,CDM,343,RC,A9562,HCPCS,,,facility,both,,,,801,600.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Kit For The Preparation Of Technetium Tc 99M Medronate: 5 Vial, Multi-Dose In 1 Kit (45567-0040-1)  / 10 Ml In 1 Vial, Multi-Dose",5413182_45567004001,CDM,343,RC,A9562,HCPCS,45567004001,NDC,facility,both,1,EA,,801,600.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Kit For The Preparation Of Technetium Tc 99M Mebrofenin: 5 Vial, Multi-Dose In 1 Kit (45567-0455-1)  / 10 Ml In 1 Vial, Multi-Dose",5413182_45567045501,CDM,343,RC,A9562,HCPCS,45567045501,NDC,facility,both,1,EA,,756,567,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Technescan Mag3: 5 Vial In 1 Cello Pack (69945-096-20)  / 1 Injection, Powder, Lyophilized, For Solution In 1 Vial",5413182_69945009620,CDM,343,RC,A9562,HCPCS,69945009620,NDC,facility,both,1,EA,,785.21,588.91,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm Tc-99M Pentetate Dx Aerosol To 75 Mci - A9567,5413183,CDM,343,RC,A9567,HCPCS,,,facility,both,,,,166,124.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Indium In 111 Oxyquinoline: 1 Vial In 1 Box (17156-021-01)  / 1 Ml In 1 Vial,5413183_17156002101,CDM,343,RC,A9567,HCPCS,17156002101,NDC,facility,both,1,EA,,157,117.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
NDC Description Not Available,5413183_52919000103,CDM,343,RC,A9567,HCPCS,52919000103,NDC,facility,both,1,EA,,160.19,120.14,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Draximage Maa: 30 Injection, Powder, For Solution In 1 Kit (65174-270-30)",5413183_65174027030,CDM,343,RC,A9567,HCPCS,65174027030,NDC,facility,both,1,EA,,157,117.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
NDC Description Not Available,5413183_65174028805,CDM,343,RC,A9567,HCPCS,65174028805,NDC,facility,both,1,EA,,161.26,120.94,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Draximage Dtpa: 30 Injection, Powder, Lyophilized, For Solution In 1 Kit (65174-288-30)",5413183_65174028830,CDM,343,RC,A9567,HCPCS,65174028830,NDC,facility,both,1,EA,,161.64,121.23,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Nm In-111 Lbld Auto Wbc Dx Per Study Dose - A9570,5413184,CDM,343,RC,A9570,HCPCS,,,facility,both,,,,6845,5133.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Indium In 111 Oxyquinoline: 1 Vial In 1 Box (17156-021-01)  / 1 Ml In 1 Vial,5413184_17156002101,CDM,343,RC,A9570,HCPCS,17156002101,NDC,facility,both,1,EA,,6673,5004.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
ORPHENADRINE CITRATE CR 100 MG TB12,54213,CDM,250,RC,43386048024,NDC,,,facility,both,1,UN,,8.3,6.22,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 60 MG CP24,54231,CDM,250,RC,228277811,NDC,,,facility,both,2,UN,,7.32,5.49,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 60 MG CP24,54231,CDM,250,RC,527411637,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 60 MG CP24,54231,CDM,250,RC,228277811,NDC,,,facility,both,1,UN,,11.3,8.48,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 80 MG CP24,54232,CDM,250,RC,60687022601,NDC,,,facility,both,2,UN,,8.42,6.32,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 80 MG CP24,54232,CDM,250,RC,527411737,NDC,,,facility,both,2,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 80 MG CP24,54232,CDM,250,RC,60687022601,NDC,,,facility,both,1,UN,,12.55,9.41,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 80 MG CP24,54232,CDM,250,RC,527411737,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG TB24,54254,CDM,250,RC,68084059801,NDC,,,facility,both,1,UN,,12.45,9.34,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG TB24,54254,CDM,250,RC,62175026137,NDC,,,facility,both,1,UN,,11.65,8.74,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG TB24,54254,CDM,250,RC,50268059815,NDC,,,facility,both,1,UN,,11.45,8.59,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG TB24,54254,CDM,250,RC,50268059815,NDC,,,facility,both,2,UN,,7.48,5.61,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG TB24,54254,CDM,250,RC,68084059801,NDC,,,facility,both,2,UN,,8.32,6.24,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG TB24,54256,CDM,250,RC,50268059715,NDC,,,facility,both,2,UN,,6,4.5,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG TB24,54256,CDM,250,RC,50268059715,NDC,,,facility,both,1,UN,,9.85,7.39,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG TB24,54256,CDM,250,RC,68084059701,NDC,,,facility,both,2,UN,,6.58,4.93,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG TB24,54256,CDM,250,RC,68084059701,NDC,,,facility,both,1,UN,,10.5,7.88,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG TB24,54256,CDM,250,RC,50268059715,NDC,,,facility,both,3,UN,,4.67,3.5,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GM/15ML SOLN,54298,CDM,250,RC,MHS1ML,HCPCS,121115400,NDC,facility,both,1,ML,,0.25,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GM/15ML SOLN 30 ML CUP,54298,CDM,250,RC,MHS1ML,HCPCS,121115400,NDC,facility,both,1,ML,,0.07,0.06,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE SOLR,54317,CDM,250,RC,55150030801,NDC,,,facility,both,0.5,ME,,75.13,56.35,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE SOLR,54317,CDM,250,RC,781315972,NDC,,,facility,both,0.5,ME,,77.71,58.29,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE SOLR,54317,CDM,636,RC,J2359,HCPCS,55150030801,NDC,facility,both,0.5,ME,,6.42,4.82,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE SOLR,54317,CDM,636,RC,J2359,HCPCS,2759701,NDC,facility,both,0.5,ME,,8.69,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE SOLR,54317,CDM,250,RC,2759701,NDC,,,facility,both,0.5,ME,,173.85,130.39,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE SOLR,54317,CDM,636,RC,J2359,HCPCS,781315972,NDC,facility,both,0.5,ME,,6.97,5.23,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE SOLR,54317,CDM,636,RC,J2359,HCPCS,517095501,NDC,facility,both,0.5,ME,,7.54,5.66,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE SOLR,54317,CDM,250,RC,517095501,NDC,,,facility,both,0.5,ME,,150.8,113.1,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 200 MG/ML SOLN 30 ML VIAL,54332,CDM,636,RC,J0132,HCPCS,72611086004,NDC,facility,both,100,ME,,2.41,1.81,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 200 MG/ML SOLN 30 ML VIAL,54332,CDM,636,RC,J0132,HCPCS,55150025930,NDC,facility,both,100,ME,,2.27,1.71,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 200 MG/ML SOLN 30 ML VIAL,54332,CDM,636,RC,J0132,HCPCS,25021081230,NDC,facility,both,100,ME,,2.23,1.67,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 200 MG/ML SOLN 30 ML VIAL,54332,CDM,636,RC,J0132,HCPCS,574080530,NDC,facility,both,100,ME,,7.17,5.38,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM 18 MCG CAPS 5 EACH BOX,54337,CDM,250,RC,MHS1CAP,HCPCS,597007575,NDC,facility,both,1,EA,,18.65,13.99,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG CP24,54413,CDM,250,RC,70010001201,NDC,,,facility,both,3,UN,,7.93,5.95,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG CP24,54413,CDM,250,RC,51862060901,NDC,,,facility,both,2,UN,,8.52,6.39,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG CP24,54413,CDM,250,RC,70010001201,NDC,,,facility,both,2,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG CP24,54413,CDM,250,RC,70010001201,NDC,,,facility,both,1,UN,,11.4,8.55,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG CP24,54413,CDM,250,RC,70010001201,NDC,,,facility,both,4,UN,,7.46,5.6,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG CP24,54413,CDM,250,RC,51862060901,NDC,,,facility,both,1,UN,,11.15,8.36,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5ML SOLN,54518,CDM,250,RC,MHS1ML,HCPCS,54838052340,NDC,facility,both,1,ML,,1.5,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 5 MG SOLR 1 EACH VIAL,54524,CDM,636,RC,J0180,HCPCS,58468004101,NDC,facility,both,1,ME,,509.83,382.37,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMINS (ADULT) INJ INJ 5 ML VIAL,54636,CDM,250,RC,MHS1ML,HCPCS,54643564901,NDC,facility,both,1,ML,,11.68,8.76,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIMICROBIAL SILVER DRESSING GEL 44.4 ML TUBE,54667,CDM,250,RC,8327030909,NDC,,,facility,both,44.4,ML,,64.13,48.1,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 6 MG/2 ML SOLN,54744,CDM,636,RC,J0153,HCPCS,25021030167,NDC,facility,both,1,ME,,12.33,9.25,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 6 MG/2 ML SOLN,54744,CDM,636,RC,J0153,HCPCS,67457085400,NDC,facility,both,1,ME,,10.09,7.57,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 6 MG/2 ML SOLN,54744,CDM,636,RC,J0153,HCPCS,67457085502,NDC,facility,both,1,ME,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 6 MG/2 ML SOLN,54744,CDM,636,RC,J0153,HCPCS,63323065104,NDC,facility,both,1,ME,,8.77,6.58,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 6 MG/2 ML SOLN,54744,CDM,636,RC,J0153,HCPCS,63323065190,NDC,facility,both,1,ME,,8.02,6.02,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 6 MG/2 ML SOLN,54744,CDM,636,RC,J0153,HCPCS,63323065189,NDC,facility,both,1,ME,,12.67,9.5,,,,,,,,,,Gross Charge Type: Pharmacy
TROSPIUM 20 MG TABS,54944,CDM,250,RC,68462046160,NDC,,,facility,both,0.5,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
TROSPIUM 20 MG TABS,54944,CDM,250,RC,68462046160,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
TROSPIUM 20 MG TABS,54944,CDM,250,RC,68462046160,NDC,,,facility,both,2,UN,,5.52,4.14,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 200 MG TABS,55031,CDM,250,RC,65649030103,NDC,,,facility,both,1,UN,,25.5,19.12,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 200 MG TABS,55031,CDM,250,RC,65649030103,NDC,,,facility,both,2,UN,,20.48,15.36,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 200 MG TABS,55031,CDM,250,RC,65649030103,NDC,,,facility,both,2.5,UN,,16.18,12.14,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 15 G BOTTLE,55106,CDM,250,RC,832046515,NDC,,,facility,both,15,GR,,59.2,44.4,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 15 G BOTTLE,55106,CDM,250,RC,16714076901,NDC,,,facility,both,15,GR,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 15 G BOTTLE,55106,CDM,250,RC,69315030615,NDC,,,facility,both,15,GR,,69.35,52.01,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 15 G BOTTLE,55106,CDM,250,RC,574200815,NDC,,,facility,both,15,GR,,68.65,51.49,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 15 G BOTTLE,55106,CDM,250,RC,68308015215,NDC,,,facility,both,15,GR,,49.3,36.98,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 30 G BOTTLE,55106,CDM,250,RC,574200830,NDC,,,facility,both,30,GR,,98.55,73.91,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 30 G BOTTLE,55106,CDM,250,RC,69315030630,NDC,,,facility,both,30,GR,,99.9,74.92,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 30 G BOTTLE,55106,CDM,250,RC,68308015230,NDC,,,facility,both,30,GR,,60.85,45.64,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 60 G BOTTLE,55106,CDM,250,RC,574200802,NDC,,,facility,both,60,GR,,145.9,109.42,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/GM POWD 60 G BOTTLE,55106,CDM,250,RC,69315030660,NDC,,,facility,both,60,GR,,145.9,109.42,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE-SIMVASTATIN 10-20 MG TABS,55192,CDM,250,RC,16714077902,NDC,,,facility,both,1,UN,,10.9,8.18,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE-SIMVASTATIN 10-20 MG TABS,55192,CDM,250,RC,45963056608,NDC,,,facility,both,1,UN,,14.4,10.8,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR DF 200-300 MG TABS,55224,CDM,636,RC,J0750,HCPCS,61958070101,NDC,facility,both,1,EA,,105.9,79.42,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR DF 200-300 MG TABS,55224,CDM,250,RC,61958070101,NDC,,,facility,both,1,EA,,105.9,79.42,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG CPEP,55244,CDM,250,RC,50268026911,NDC,,,facility,both,2,UN,,5.9,4.42,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG CPEP,55244,CDM,250,RC,904704304,NDC,,,facility,both,2,UN,,6.82,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG CPEP,55244,CDM,250,RC,60687072321,NDC,,,facility,both,2,UN,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG CPEP,55244,CDM,250,RC,60687072321,NDC,,,facility,both,1,UN,,9.42,7.07,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG CPEP,55244,CDM,250,RC,904704304,NDC,,,facility,both,3,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG CPEP,55244,CDM,250,RC,60687072321,NDC,,,facility,both,3,UN,,4.33,3.25,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG CPEP,55244,CDM,250,RC,50268026911,NDC,,,facility,both,1,UN,,9.63,7.22,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG CPEP,55244,CDM,250,RC,904704304,NDC,,,facility,both,1,UN,,10.68,8.01,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,50268027013,NDC,,,facility,both,2,UN,,5.73,4.3,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,904704461,NDC,,,facility,both,3,UN,,5.43,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,60687073401,NDC,,,facility,both,1,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,57237001830,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,904704461,NDC,,,facility,both,2,UN,,6.82,5.12,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,904704461,NDC,,,facility,both,4,UN,,4.7,3.52,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,904704461,NDC,,,facility,both,1,UN,,10.75,8.06,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,57237001830,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,60687073411,NDC,,,facility,both,2,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,60687073401,NDC,,,facility,both,2,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,60687073411,NDC,,,facility,both,1,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG CPEP,55245,CDM,250,RC,50268027013,NDC,,,facility,both,1,UN,,9.57,7.18,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,60687074501,NDC,,,facility,both,0.5,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,904704561,NDC,,,facility,both,1,UN,,8.66,6.5,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,60687074501,NDC,,,facility,both,1,UN,,8.22,6.17,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,60687074501,NDC,,,facility,both,1.5,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,904704561,NDC,,,facility,both,1.3333,UN,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,904704561,NDC,,,facility,both,2,UN,,5.72,4.29,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,904704561,NDC,,,facility,both,1.5,UN,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,60687074501,NDC,,,facility,both,2,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,57237001930,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG CPEP,55246,CDM,250,RC,904704561,NDC,,,facility,both,0.5,UN,,6.72,5.04,,,,,,,,,,Gross Charge Type: Pharmacy
ARGININE 1000 MG TABS,55362,CDM,250,RC,11822363280,NDC,,,facility,both,3,UN,,3.23,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-POLYETHYLENE GLYCOL 420 G SOLR,55436,CDM,250,RC,64380076921,NDC,,,facility,both,1000,ML,,23.1,17.32,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-POLYETHYLENE GLYCOL 420 G SOLR,55436,CDM,250,RC,64380076921,NDC,,,facility,both,2000,ML,,38.7,29.02,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-POLYETHYLENE GLYCOL 420 G SOLR,55436,CDM,250,RC,64380076921,NDC,,,facility,both,4000,ML,,69.25,51.94,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GM/15ML SOLN,55445,CDM,250,RC,60432003816,NDC,,,facility,both,30,ML,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPENEM-CILASTATIN 500 SOLR 1 EACH VIAL,55454,CDM,636,RC,J0743,HCPCS,6351659,NDC,facility,both,250,ME,,66.48,49.86,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPENEM-CILASTATIN 500 SOLR 1 EACH VIAL,55454,CDM,636,RC,J0743,HCPCS,63323032225,NDC,facility,both,250,ME,,38.55,28.91,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 12 MG/4 ML SOLN,55479,CDM,636,RC,J0153,HCPCS,25021030168,NDC,facility,both,1,ME,,6.92,5.19,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 12 MG/4 ML SOLN,55479,CDM,636,RC,J0153,HCPCS,63323065104,NDC,facility,both,1,ME,,8.77,6.58,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 12 MG/4 ML SOLN,55479,CDM,636,RC,J0153,HCPCS,67457085400,NDC,facility,both,1,ME,,5.67,4.25,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 12 MG/4 ML SOLN,55479,CDM,636,RC,J0153,HCPCS,63323065189,NDC,facility,both,1,ME,,12.67,9.5,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 12 MG/4 ML SOLN,55479,CDM,636,RC,J0153,HCPCS,63323065190,NDC,facility,both,1,ME,,8.02,6.02,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 12 MG/4 ML SOLN,55479,CDM,636,RC,J0153,HCPCS,67457085502,NDC,facility,both,1,ME,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,5553,CDM,63323004401,NDC,,,,,facility,both,1000,ML,,29.78,22.33,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,5553,CDM,517003125,NDC,,,,,facility,both,1000,ML,,20.71,15.53,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,5553,CDM,517003101,NDC,,,,,facility,both,1000,ML,,14,10.5,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,5553,CDM,63323004400,NDC,,,,,facility,both,1000,ML,,17.9,13.43,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,5553,CDM,63323004401,NDC,,,,,facility,both,1000,ML,,5,3.75,,,,,,,,,,Gross Charge Type: Pharmacy
"CYANOCOBALAMIN B12 1,000 MCG/ML SOLN",5553,CDM,636,RC,J3420,HCPCS,143962125,NDC,facility,both,1,ML,,48.4,36.3,,,,,,,,,,Gross Charge Type: Pharmacy
"CYANOCOBALAMIN B12 1,000 MCG/ML SOLN",5553,CDM,636,RC,J3420,HCPCS,63323004401,NDC,facility,both,1,ML,,24.75,18.57,,,,,,,,,,Gross Charge Type: Pharmacy
"CYANOCOBALAMIN B12 1,000 MCG/ML SOLN",5553,CDM,636,RC,J3420,HCPCS,67457039910,NDC,facility,both,1,ML,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
"CYANOCOBALAMIN B12 1,000 MCG/ML SOLN",5553,CDM,636,RC,J3420,HCPCS,517003125,NDC,facility,both,1,ML,,47.11,35.34,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML (5 ML) SOLN,55722,CDM,250,RC,143978410,NDC,,,facility,both,2,ML,,44.2,33.15,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML (5 ML) SOLN,55722,CDM,250,RC,143978410,NDC,,,facility,both,4,ML,,44.2,33.15,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML (5 ML) SOLN,55722,CDM,250,RC,63323042405,NDC,,,facility,both,2,ML,,44.35,33.26,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML (5 ML) SOLN,55722,CDM,250,RC,143978410,NDC,,,facility,both,10,ML,,31.7,23.78,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML (5 ML) SOLN,55722,CDM,250,RC,143978410,NDC,,,facility,both,1,ML,,44.2,33.15,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML (5 ML) SOLN,55722,CDM,250,RC,143978410,NDC,,,facility,both,3,ML,,44.2,33.15,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML (5 ML) SOLN,55722,CDM,250,RC,143978410,NDC,,,facility,both,5,ML,,44.2,33.15,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,50268019115,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,591565801,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,93342201,NDC,,,facility,both,0.75,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,50268019115,NDC,,,facility,both,1,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,93342201,NDC,,,facility,both,0.5,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,93342201,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,60687055801,NDC,,,facility,both,0.75,UN,,6.75,5.06,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,60687055801,NDC,,,facility,both,1,UN,,6.95,5.21,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,591565801,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG TABS,5573,CDM,250,RC,60687055801,NDC,,,facility,both,0.5,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAFLUORPROP-TETRAFLUOROETH AERO 116 ML CAN,55781,CDM,250,RC,MHS1ML,HCPCS,386000802,NDC,facility,both,1,ML,,0.74,0.56,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,5582,CDM,250,RC,MHS1ML,HCPCS,61314039601,NDC,facility,both,1,ML,,22.8,17.1,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPENTOLATE 1 % SOLN 2 ML BOTTLE,5582,CDM,250,RC,MHS1ML,HCPCS,24208073501,NDC,facility,both,1,ML,,22.92,17.19,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 40 MG/ML SOLN 2 ML VIAL,55897,CDM,636,RC,J3260,HCPCS,63323030602,NDC,facility,both,2,ML,,14.86,11.15,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 48 MG TABS,55990,CDM,250,RC,60687061811,NDC,,,facility,both,1,UN,,10.35,7.76,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 48 MG TABS,55990,CDM,250,RC,68084063521,NDC,,,facility,both,3.020833333,UN,,3.82,2.87,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 48 MG TABS,55990,CDM,250,RC,60687061811,NDC,,,facility,both,2,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 48 MG TABS,55990,CDM,250,RC,68084063521,NDC,,,facility,both,1,UN,,10.35,7.76,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 48 MG TABS,55990,CDM,250,RC,60687061811,NDC,,,facility,both,3,UN,,5.08,3.81,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 145 MG TABS,55991,CDM,250,RC,60687062921,NDC,,,facility,both,1,UN,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 145 MG TABS,55991,CDM,250,RC,60687062901,NDC,,,facility,both,1,UN,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 145 MG TABS,55991,CDM,250,RC,63304044990,NDC,,,facility,both,1,UN,,9.04,6.78,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 2 MG/5ML SYRP,5603,CDM,250,RC,MHS1ML,HCPCS,64980050448,NDC,facility,both,1,ML,,0.63,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 15 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,both,50,ME,,13.46,10.1,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 15 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,703424601,NDC,facility,both,50,ME,,12.65,9.49,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 15 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,54288016501,NDC,facility,both,50,ME,,34.45,25.84,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 45 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,703424801,NDC,facility,both,50,ME,,12.69,9.52,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 45 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,both,50,ME,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 5 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,54288016401,NDC,facility,both,50,ME,,34.9,26.18,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 5 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,61703033918,NDC,facility,both,50,ME,,33.7,25.27,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 5 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,703424401,NDC,facility,both,50,ME,,26.01,19.5,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 60 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,63323017260,NDC,facility,both,50,ME,,33.88,25.41,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 60 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,61703033956,NDC,facility,both,50,ME,,8.89,6.67,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 60 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,16729029512,NDC,facility,both,50,ME,,11.32,8.49,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 60 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,703423901,NDC,facility,both,50,ME,,18.29,13.72,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML SOLN 60 ML VIAL,56037,CDM,636,RC,J9045,HCPCS,55150038601,NDC,facility,both,50,ME,,9.66,7.24,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG TABS,5604,CDM,250,RC,70710111001,NDC,,,facility,both,1,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2,ML,,92.86,69.64,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5.4,ML,,161.78,121.34,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5.8,ML,,173.87,130.4,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3.6,ML,,130.82,98.11,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3.1,ML,,115.89,86.92,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,7.3,ML,,219.05,164.29,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2.2,ML,,97.6,73.2,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3.4,ML,,123.33,92.5,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2.6,ML,,104.02,78.02,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5.7,ML,,181.65,136.24,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,8.8,ML,,253.8,190.35,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5,ML,,162.73,122.05,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2.8,ML,,112.48,84.36,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4.8,ML,,154.02,115.52,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2.4,ML,,104.45,78.34,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,6.3,ML,,195.6,146.7,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,8.1,ML,,237.75,178.31,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3.5,ML,,127.8,95.85,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,6,ML,,188.6,141.45,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,7.6,ML,,226.1,169.58,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4.4,ML,,149.6,112.2,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3.8,ML,,134.43,100.83,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5.3,ML,,172.45,129.34,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,7.5,ML,,223.75,167.81,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,8.3,ML,,242.4,181.8,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4.5,ML,,142.1,106.58,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5.6,ML,,179.35,134.51,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2.7,ML,,106.93,80.2,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,9.1,ML,,260.55,195.41,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,6.6,ML,,202.65,151.99,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2.5,ML,,102.28,76.71,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,1.9,ML,,93.9,70.42,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5.1,ML,,153.1,114.82,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3,ML,,117.16,87.87,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4,ML,,137.07,102.8,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,1.6,ML,,82.3,61.72,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,6.1,ML,,177.56,133.17,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,6.8,ML,,197.28,147.96,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3.2,ML,,123.95,92.96,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2.3,ML,,96.4,72.3,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3.9,ML,,134.91,101.18,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5.2,ML,,162.62,121.97,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,9.3,ML,,238.35,178.76,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4.7,ML,,157.73,118.3,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,8.6,ML,,249.25,186.94,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4.9,ML,,156.18,117.13,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,7.1,ML,,193.35,145.01,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,8.2,ML,,240.05,180.04,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4.2,ML,,142.39,106.79,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4.1,ML,,142.58,106.93,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,6.7,ML,,202.17,151.63,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,1.8,ML,,86.35,64.76,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,8,ML,,219.65,164.74,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2.1,ML,,96.45,72.34,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,7.9,ML,,209.7,157.28,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,8.7,ML,,251.5,188.62,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5.9,ML,,186.25,139.69,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,7.4,ML,,221.4,166.05,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,7.7,ML,,220.88,165.66,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,2.9,ML,,113.05,84.79,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,10.3,ML,,145.08,108.81,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,6.5,ML,,200.3,150.22,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4.3,ML,,145.25,108.94,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3.3,ML,,122.44,91.83,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,4.6,ML,,147.42,110.56,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,5.5,ML,,177.05,132.79,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,7.8,ML,,230.8,173.1,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,6.2,ML,,193.3,144.98,,,,,,,,,,Gross Charge Type: Pharmacy
CYSTEINE 50 MG/ML SOLN 10 ML VIAL,5607,CDM,250,RC,51754100703,NDC,,,facility,both,3.7,ML,,132.6,99.45,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG TBEC,56095,CDM,250,RC,68462043518,NDC,,,facility,both,2,UN,,5.67,4.25,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG TBEC,56095,CDM,250,RC,68462043518,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM 500 MG CHEW,56102,CDM,250,RC,54092025290,NDC,,,facility,both,2,UN,,7.08,5.31,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM 500 MG CHEW,56102,CDM,250,RC,54092025290,NDC,,,facility,both,4,UN,,4.92,3.69,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM 500 MG CHEW,56102,CDM,250,RC,66993042285,NDC,,,facility,both,2,UN,,16.88,12.66,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM 500 MG CHEW,56102,CDM,250,RC,66993042285,NDC,,,facility,both,4,UN,,14.22,10.67,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM 500 MG CHEW,56102,CDM,250,RC,66993042285,NDC,,,facility,both,1,UN,,21.7,16.28,,,,,,,,,,Gross Charge Type: Pharmacy
NATALIZUMAB 20 MG/ML CONC 15 ML VIAL,56120,CDM,636,RC,J2323,HCPCS,64406000801,NDC,facility,both,1,ME,,67.48,50.61,,,,,,,,,,Gross Charge Type: Pharmacy
ESZOPICLONE 1 MG TABS,56322,CDM,250,RC,33342029907,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
ESZOPICLONE 1 MG TABS,56322,CDM,250,RC,33342029907,NDC,,,facility,both,3,UN,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
ESZOPICLONE 1 MG TABS,56322,CDM,250,RC,33342029907,NDC,,,facility,both,1,UN,,5.9,4.42,,,,,,,,,,Gross Charge Type: Pharmacy
SOLIFENACIN 5 MG TABS,56365,CDM,250,RC,50228042730,NDC,,,facility,both,1,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
SOLIFENACIN 5 MG TABS,56365,CDM,250,RC,51248015001,NDC,,,facility,both,1,UN,,30.85,23.14,,,,,,,,,,Gross Charge Type: Pharmacy
SOLIFENACIN 5 MG TABS,56365,CDM,250,RC,50228042730,NDC,,,facility,both,2,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
SOLIFENACIN 10 MG TABS,56366,CDM,250,RC,50228042830,NDC,,,facility,both,1,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
DARIFENACIN HYDROBROMIDE 7.5 MG TB24,56369,CDM,250,RC,13668020230,NDC,,,facility,both,2,UN,,10.15,7.61,,,,,,,,,,Gross Charge Type: Pharmacy
DARIFENACIN HYDROBROMIDE 15 MG TB24,56370,CDM,250,RC,33342027707,NDC,,,facility,both,1,UN,,12.3,9.22,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 1000 MG SUPP,56559,CDM,250,RC,69918056030,NDC,,,facility,both,1,UN,,34.7,26.02,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL (PROTEIN-BOUND) 5 MG/ML SUSR 1 EACH VIAL,56568,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,both,1,ME,,46.42,34.82,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE ACETATE (6 MONTH) 45 MG KIT,56775,CDM,636,RC,J9217,HCPCS,62935045345,NDC,facility,both,7.5,ME,,375.25,281.44,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE ACETATE (6 MONTH) 45 MG KIT,56775,CDM,636,RC,J9217,HCPCS,62935046150,NDC,facility,both,7.5,ME,,324.63,243.47,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5ML SUSR,56802,CDM,250,RC,MHS1ML,HCPCS,68180015001,NDC,facility,both,1,ML,,5.1,3.82,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5ML SUSR,56802,CDM,250,RC,MHS1ML,HCPCS,68382044405,NDC,facility,both,1,ML,,5.04,3.78,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 54 MG TABS,56807,CDM,250,RC,50268031211,NDC,,,facility,both,1,UN,,9.8,7.35,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 54 MG TABS,56807,CDM,250,RC,50268031211,NDC,,,facility,both,2,UN,,5.92,4.44,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 54 MG TABS,56807,CDM,250,RC,115551110,NDC,,,facility,both,1,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 160 MG TABS,56808,CDM,250,RC,71205094930,NDC,,,facility,both,1,UN,,7.5,5.62,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE 160 MG TABS,56808,CDM,250,RC,60219552209,NDC,,,facility,both,1,UN,,7.95,5.96,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE SOLR,56813,CDM,250,RC,70100042402,NDC,,,facility,both,0.1,UN,,156.8,117.6,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE SOLR,56813,CDM,250,RC,70100042402,NDC,,,facility,both,0.2,UN,,263.5,197.62,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE SOLR,56813,CDM,250,RC,70100042402,NDC,,,facility,both,0.6,UN,,731.65,548.74,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 44 MCG/ACT AERO 10.6 G INHALER,56819,CDM,250,RC,MHS1GM,HCPCS,66993007896,NDC,facility,both,1,GM,,19.15,14.36,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACT AERO 12 G INHALER,56820,CDM,250,RC,MHS1GM,HCPCS,66993007996,NDC,facility,both,1,GM,,22.75,17.06,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 220 MCG/ACT AERO 12 G INHALER,56821,CDM,250,RC,MHS1GM,HCPCS,66993008096,NDC,facility,both,1,GM,,34.11,25.58,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (2 ML) SOLN,56883,CDM,636,RC,J2250,HCPCS,409230517,NDC,facility,both,1,ME,,21.42,16.07,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML (2 ML) SOLN,56883,CDM,636,RC,J2250,HCPCS,23155060041,NDC,facility,both,1,ME,,14.72,11.04,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) 2 GM/SUPP SUPP,57015,CDM,250,RC,132007950,NDC,,,facility,both,1,UN,,20.1,15.08,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 2 GM/SUPP SUPP,57015,CDM,250,RC,132007950,NDC,,,facility,both,2,UN,,10.12,7.59,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 2 GM/SUPP SUPP,57015,CDM,250,RC,132007950,NDC,,,facility,both,1,UN,,20.1,15.08,,,,,,,,,,Gross Charge Type: Pharmacy
ENTECAVIR 0.5 MG TABS,57167,CDM,250,RC,16714071701,NDC,,,facility,both,1,UN,,11.35,8.51,,,,,,,,,,Gross Charge Type: Pharmacy
ENTECAVIR 0.5 MG TABS,57167,CDM,250,RC,3161112,NDC,,,facility,both,1,UN,,82.4,61.8,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE SOLR 1 EACH VIAL,5722,CDM,636,RC,J9130,HCPCS,143924510,NDC,facility,both,100,ME,,20.66,15.5,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE SOLR 1 EACH VIAL,5722,CDM,636,RC,J9130,HCPCS,63323012820,NDC,facility,both,100,ME,,14.19,10.64,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML SOLN,57292,CDM,636,RC,A9577,HCPCS,270516412,NDC,facility,both,1,ML,,7.67,5.75,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML SOLN,57292,CDM,636,RC,A9577,HCPCS,270516415,NDC,facility,both,1,ML,,6.72,5.04,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML SOLN,57292,CDM,636,RC,A9577,HCPCS,270516414,NDC,facility,both,1,ML,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML SOLN,57292,CDM,636,RC,A9577,HCPCS,270516413,NDC,facility,both,1,ML,,9.34,7,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM HFA 17 MCG/ACTUATION AERS 12.9 G INHALER,57293,CDM,250,RC,MHS1GM,HCPCS,597008717,NDC,facility,both,1,GM,,49.67,37.25,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN SODIUM 50 MG SOLR 1 EACH VIAL,57294,CDM,636,RC,J2248,HCPCS,143936101,NDC,facility,both,1,ME,,3.14,2.36,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN SODIUM 50 MG SOLR 1 EACH VIAL,57294,CDM,636,RC,J2248,HCPCS,469325010,NDC,facility,both,1,ME,,5.69,4.27,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTHERIA, TETANUS, ACELLULAR PERTUSSIS VACCINE (PEDIATRIC >/= 7 YEARS) 5-2.5-18.5 LF-MCG/0.5 SUSP",57323,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,both,0.5,ML,,115,86.25,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP,57323,CDM,58160084243,NDC,,,,,facility,both,0.5,ML,,115.25,86.44,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP,57323,CDM,58160084252,NDC,,,,,facility,both,0.5,ML,,60.38,45.28,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP,57323,CDM,58160084243,NDC,,,,,facility,both,0.5,ML,,41,30.75,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP,57323,CDM,58160084252,NDC,,,,,facility,both,0.5,ML,,55.04,41.28,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP,57323,CDM,58160084252,NDC,,,,,facility,both,0.5,ML,,25,18.75,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP,57323,CDM,58160084252,NDC,,,,,facility,both,0.5,ML,,42.6,31.95,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDARABINE 25 MG/ML SOLN 2 ML VIAL,57324,CDM,636,RC,J9185,HCPCS,63323019202,NDC,facility,both,50,ME,,158.95,119.21,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDARABINE 25 MG/ML SOLN 2 ML VIAL,57324,CDM,636,RC,J9185,HCPCS,25021024202,NDC,facility,both,50,ME,,147.05,110.29,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 12 MCG/HR PT72,57416,CDM,250,RC,47781042347,NDC,,,facility,both,1,UN,,12.55,9.41,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 12 MCG/HR PT72,57416,CDM,250,RC,378911998,NDC,,,facility,both,1,UN,,27.15,20.36,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMETHYLPHENIDATE 5 MG CP24,57608,CDM,250,RC,16714056201,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMETHYLPHENIDATE 5 MG CP24,57608,CDM,250,RC,527810637,NDC,,,facility,both,1,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMETHYLPHENIDATE 10 MG CP24,57611,CDM,250,RC,93555101,NDC,,,facility,both,2,UN,,17.22,12.92,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMETHYLPHENIDATE 10 MG CP24,57611,CDM,250,RC,16714056301,NDC,,,facility,both,2,UN,,3.04,2.28,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMETHYLPHENIDATE 10 MG CP24,57611,CDM,250,RC,16714056301,NDC,,,facility,both,1,UN,,4.14,3.1,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMETHYLPHENIDATE 10 MG CP24,57611,CDM,250,RC,527810737,NDC,,,facility,both,1,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMETHYLPHENIDATE 10 MG CP24,57611,CDM,250,RC,93555101,NDC,,,facility,both,1,UN,,20,15,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMETHYLPHENIDATE 10 MG CP24,57611,CDM,250,RC,527810737,NDC,,,facility,both,2,UN,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG SOLR,57707,CDM,636,RC,J1611,HCPCS,63323059613,NDC,facility,both,1,ME,,352.13,264.1,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG SOLR,57707,CDM,636,RC,J1610,HCPCS,63323059603,NDC,facility,both,1,ME,,368.1,276.08,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG SOLR,57707,CDM,636,RC,J1611,HCPCS,63323059303,NDC,facility,both,1,ME,,321.96,241.47,,,,,,,,,,Gross Charge Type: Pharmacy
L-CARNITINE 1 GM/10ML SOLN,57798,CDM,250,RC,MHS10ML,HCPCS,64980050312,NDC,facility,both,10,ML,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML SOLN,57799,CDM,636,RC,J3430,HCPCS,409915701,NDC,facility,both,1,ME,,53.9,40.43,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML SOLN,57799,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,both,1,ME,,110.27,82.7,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 2 MG/ML SOLN,57799,CDM,636,RC,J3430,HCPCS,409915701,NDC,facility,both,1,ME,,53.9,40.42,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 2 MG/ML SOLN,57799,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,both,1,ME,,110.65,82.99,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMIN K1 1 MG/0.5ML IJ SOLN,57799,CDM,76329124001,NDC,,,,,facility,both,1,ML,,16,12,,,,,,,,,,Gross Charge Type: Pharmacy
"TETANUS, DIPHTHERIA, ACELLULAR PERTUSSIS VACCINE 5-2-15.5 LF-MCG/0.5 SUSP",57803,CDM,636,RC,90715,HCPCS,49281040010,NDC,facility,both,0.5,ML,,171.58,128.68,,,,,,,,,,Gross Charge Type: Pharmacy
TIGECYCLINE SOLR 1 EACH VIAL,57827,CDM,636,RC,J3243,HCPCS,70121164707,NDC,facility,both,1,ME,,4.65,3.49,,,,,,,,,,Gross Charge Type: Pharmacy
DANAZOL 200 MG CAPS,5787,CDM,250,RC,555063509,NDC,,,facility,both,2,UN,,12.88,9.66,,,,,,,,,,Gross Charge Type: Pharmacy
DANAZOL 200 MG CAPS,5787,CDM,250,RC,555063509,NDC,,,facility,both,1,UN,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 20 MG TABS,57972,CDM,250,RC,904667104,NDC,,,facility,both,1,UN,,9.35,7.01,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 20 MG TABS,57972,CDM,250,RC,50268071715,NDC,,,facility,both,2,UN,,5.65,4.24,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 20 MG TABS,57972,CDM,250,RC,93551798,NDC,,,facility,both,0.5,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 20 MG TABS,57972,CDM,250,RC,93551798,NDC,,,facility,both,1,UN,,9.6,7.2,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 20 MG TABS,57972,CDM,250,RC,50268071715,NDC,,,facility,both,0.5,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 20 MG TABS,57972,CDM,250,RC,50268071715,NDC,,,facility,both,1,UN,,9.5,7.12,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE 100 MG TABS,5803,CDM,250,RC,70954013610,NDC,,,facility,both,0.5,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE 100 MG TABS,5803,CDM,250,RC,70954013610,NDC,,,facility,both,1,UN,,10.3,7.72,,,,,,,,,,Gross Charge Type: Pharmacy
OMEGA-3-FATTY ACIDS ETHYL ESTERS 1 G CAPS,58201,CDM,250,RC,60505317007,NDC,,,facility,both,2,UN,,5.58,4.18,,,,,,,,,,Gross Charge Type: Pharmacy
OMEGA-3-FATTY ACIDS ETHYL ESTERS 1 G CAPS,58201,CDM,250,RC,60505317007,NDC,,,facility,both,1,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
RAMELTEON 8 MG TABS,58205,CDM,250,RC,50268070811,NDC,,,facility,both,2,UN,,10.98,8.23,,,,,,,,,,Gross Charge Type: Pharmacy
RAMELTEON 8 MG TABS,58205,CDM,250,RC,50268070811,NDC,,,facility,both,1,UN,,15.4,11.55,,,,,,,,,,Gross Charge Type: Pharmacy
RAMELTEON 8 MG TABS,58205,CDM,250,RC,64764080530,NDC,,,facility,both,1,UN,,30.8,23.1,,,,,,,,,,Gross Charge Type: Pharmacy
RAMELTEON 8 MG TABS,58205,CDM,250,RC,52817023510,NDC,,,facility,both,1,UN,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
RAMELTEON 8 MG TABS,58205,CDM,250,RC,50268070811,NDC,,,facility,both,0.5,UN,,11.7,8.78,,,,,,,,,,Gross Charge Type: Pharmacy
RAMELTEON 8 MG TABS,58205,CDM,250,RC,52817023530,NDC,,,facility,both,1,UN,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,904699104,NDC,,,facility,both,3,UN,,4.42,3.31,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,60687047301,NDC,,,facility,both,1,UN,,6.14,4.6,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,60687047301,NDC,,,facility,both,6,UN,,1.92,1.44,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,60687047301,NDC,,,facility,both,3,UN,,2.78,2.09,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,60687047301,NDC,,,facility,both,2,UN,,3.63,2.73,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,904699104,NDC,,,facility,both,2,UN,,5.26,3.95,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,904699104,NDC,,,facility,both,4,UN,,3.99,2.99,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,60687047301,NDC,,,facility,both,4,UN,,2.35,1.76,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,904699104,NDC,,,facility,both,1,UN,,7.88,5.91,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 25 MG CAPS,58260,CDM,250,RC,904699104,NDC,,,facility,both,6,UN,,3.55,2.66,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,904699261,NDC,,,facility,both,4,UN,,2.84,2.13,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,60687048401,NDC,,,facility,both,3,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,904699261,NDC,,,facility,both,2,UN,,4.12,3.09,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,71101341,NDC,,,facility,both,1,UN,,23.76,17.82,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,904699261,NDC,,,facility,both,3,UN,,3.27,2.45,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,60687048401,NDC,,,facility,both,1,UN,,6,4.5,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,60687048401,NDC,,,facility,both,2,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,904699261,NDC,,,facility,both,1,UN,,6.22,4.67,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,72205001290,NDC,,,facility,both,2,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 50 MG CAPS,58261,CDM,250,RC,72205001290,NDC,,,facility,both,1,UN,,4.9,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,904700061,NDC,,,facility,both,1.6667,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,60687049501,NDC,,,facility,both,0.666666667,UN,,5.85,4.39,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,60687049501,NDC,,,facility,both,1.3333,UN,,1.96,1.47,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,904700061,NDC,,,facility,both,4,UN,,2.86,2.15,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,904700061,NDC,,,facility,both,0.6667,UN,,2.78,2.09,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,60687049501,NDC,,,facility,both,0.6667,UN,,0.7,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,60687049501,NDC,,,facility,both,4,UN,,2.29,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,904700061,NDC,,,facility,both,2,UN,,3.89,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,60687049501,NDC,,,facility,both,2.6667,UN,,2.62,1.96,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,71101441,NDC,,,facility,both,2,UN,,21.42,16.07,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,904700061,NDC,,,facility,both,1.3333,UN,,2.35,1.76,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,71101441,NDC,,,facility,both,4,UN,,19.64,14.73,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,71101441,NDC,,,facility,both,3,UN,,20.35,15.26,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,60687049501,NDC,,,facility,both,0.3333,UN,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,71101441,NDC,,,facility,both,1,UN,,24.4,18.3,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,904700061,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,904700061,NDC,,,facility,both,2.3333,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,60687049501,NDC,,,facility,both,1,UN,,5.12,3.84,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,904700061,NDC,,,facility,both,3,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,60687049501,NDC,,,facility,both,3,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 75 MG CAPS,58262,CDM,250,RC,60687049501,NDC,,,facility,both,2,UN,,3.31,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG CAPS,58263,CDM,250,RC,904700161,NDC,,,facility,both,6,UN,,2.58,1.93,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG CAPS,58263,CDM,250,RC,71101541,NDC,,,facility,both,2,UN,,21.42,16.07,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG CAPS,58263,CDM,250,RC,904700161,NDC,,,facility,both,2,UN,,4.13,3.1,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG CAPS,58263,CDM,250,RC,904700161,NDC,,,facility,both,3,UN,,3.43,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG CAPS,58263,CDM,250,RC,904700161,NDC,,,facility,both,4,UN,,2.36,1.77,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG CAPS,58263,CDM,250,RC,71101541,NDC,,,facility,both,1,UN,,23.95,17.96,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG CAPS,58263,CDM,250,RC,904700161,NDC,,,facility,both,1.25,UN,,3.68,2.76,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG CAPS,58263,CDM,250,RC,904700161,NDC,,,facility,both,1,UN,,5.82,4.36,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG CAPS,58263,CDM,250,RC,904700161,NDC,,,facility,both,1.5,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % OINT 35.44 G TUBE,58735,CDM,250,RC,MHS1GM,HCPCS,16714087801,NDC,facility,both,1,GM,,1.51,1.13,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % OINT 35.44 G TUBE,58735,CDM,250,RC,MHS1GM,HCPCS,168020437,NDC,facility,both,1,GM,,10.68,8.01,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN PRENATAL-IRON-FOLIC ACID 27-0.8 MG TABS,59192,CDM,250,RC,904531360,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 2 MG/ML SOLN,5965,CDM,636,RC,J2795,HCPCS,63323028507,NDC,facility,both,1,ME,,4.85,3.63,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 2 MG/ML SOLN,5965,CDM,636,RC,J2795,HCPCS,63323028513,NDC,facility,both,1,ME,,1.51,1.13,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 10 MG/ML SOLN,5967,CDM,636,RC,J2795,HCPCS,63323028820,NDC,facility,both,1,ME,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
"PR INJECTION, BUPIVICAINE, NOT OTHERWISE SPECIFIED, 0.5 MG",5972,CDM,636,RC,FAMRXNC,HCPCS,63323028635,NDC,facility,both,1,ME,,0.06,0.05,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,250,RC,FAMRXNC,HCPCS,43066001910,NDC,facility,both,1,ME,,2.69,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,FAMRXNC,HCPCS,70069006410,NDC,facility,both,1,ME,,0.79,0.59,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,J2795,HCPCS,55150019830,NDC,facility,both,1,ME,,1.74,1.3,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,J2795,HCPCS,70069006410,NDC,facility,both,1,ME,,0.46,0.34,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,250,RC,FAMRXNC,HCPCS,55150019830,NDC,facility,both,1,ME,,2.73,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,250,RC,FAMRXNC,HCPCS,63323028623,NDC,facility,both,1,ME,,2.8,2.1,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,FAMRXNC,HCPCS,63323028635,NDC,facility,both,1,ME,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,FAMRXNC,HCPCS,43066002301,NDC,facility,both,1,ME,,0.04,0.03,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,FAMRXNC,HCPCS,55150019720,NDC,facility,both,1,ME,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,250,RC,FAMRXNC,HCPCS,63323028635,NDC,facility,both,1,ME,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,250,RC,FAMRXNC,HCPCS,70069006410,NDC,facility,both,1,ME,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,J2795,HCPCS,70069006425,NDC,facility,both,1,ME,,0.5,0.38,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,250,RC,J2795,HCPCS,70069006410,NDC,facility,both,1,ME,,0.48,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,J2795,HCPCS,55150019720,NDC,facility,both,1,ME,,0.06,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,J2795,HCPCS,63323028635,NDC,facility,both,1,ME,,0.62,0.47,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,636,RC,J2795,HCPCS,63323028623,NDC,facility,both,1,ME,,2.57,1.93,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN,5972,CDM,250,RC,J2795,HCPCS,70069006425,NDC,facility,both,1,ME,,0.52,0.39,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN 100 ML VIAL,5972,CDM,250,RC,J2795,HCPCS,63323028600,NDC,facility,both,1,ME,,0.28,0.21,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN 100 ML VIAL,5972,CDM,636,RC,J2795,HCPCS,63323028603,NDC,facility,both,1,ME,,0.26,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN 100 ML VIAL,5972,CDM,636,RC,J2795,HCPCS,63323028600,NDC,facility,both,1,ME,,0.26,0.19,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN 20 ML VIAL,5972,CDM,636,RC,J2795,HCPCS,55150019720,NDC,facility,both,1,ME,,0.35,0.26,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN 30 ML VIAL,5972,CDM,250,RC,J2795,HCPCS,70069006410,NDC,facility,both,1,ME,,0.48,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN 30 ML VIAL,5972,CDM,250,RC,J2795,HCPCS,70069006425,NDC,facility,both,1,ME,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN 30 ML VIAL,5972,CDM,636,RC,J2795,HCPCS,70069006410,NDC,facility,both,1,ME,,0.47,0.35,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN 30 ML VIAL,5972,CDM,250,RC,J2795,HCPCS,63323028635,NDC,facility,both,1,ME,,0.32,0.24,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 5 MG/ML SOLN 30 ML VIAL,5972,CDM,636,RC,J2795,HCPCS,63323028635,NDC,facility,both,1,ME,,0.36,0.27,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE HCL 5 MG/ML IJ SOLN,5972,CDM,70069006410,NDC,,,,,facility,both,1,ML,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE HCL 5 MG/ML IJ SOLN,5972,CDM,63323028635,NDC,,,,,facility,both,1,ML,,2.73,2.05,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE HCL 5 MG/ML IJ SOLN,5972,CDM,55150019830,NDC,,,,,facility,both,1,ML,,3.01,2.25,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE HCL 5 MG/ML IJ SOLN,5972,CDM,43066001910,NDC,,,,,facility,both,1,ML,,2.69,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE HCL 5 MG/ML IJ SOLN,5972,CDM,63323028623,NDC,,,,,facility,both,1,ML,,1.49,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 0.05 MG/ML SOLN,59761,CDM,250,RC,MHS1ML,HCPCS,54005746,NDC,facility,both,1,ML,,6.32,4.74,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % SOLN,59924,CDM,250,RC,76329630005,NDC,,,facility,both,1,ML,,48.35,36.26,,,,,,,,,,Gross Charge Type: Pharmacy
BRIMONIDINE 0.1 % SOLN 5 ML BOTTLE,59937,CDM,250,RC,23932105,NDC,,,facility,both,5,ML,,296.1,222.08,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG SOLR 1 EACH VIAL,59943,CDM,636,RC,J0129,HCPCS,3218713,NDC,facility,both,10,ME,,130.92,98.19,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,60687015721,NDC,,,facility,both,1,UN,,20.1,15.08,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,60687015721,NDC,,,facility,both,4,UN,,12.79,9.59,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,16714014101,NDC,,,facility,both,1,UN,,7.78,5.83,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,16714014101,NDC,,,facility,both,2.5,UN,,3.07,2.3,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,16714014101,NDC,,,facility,both,3,UN,,3.18,2.39,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,60687015721,NDC,,,facility,both,0.5,UN,,14.35,10.76,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,60687015721,NDC,,,facility,both,2,UN,,15.42,11.57,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,16714014101,NDC,,,facility,both,2,UN,,4.33,3.25,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,60687015721,NDC,,,facility,both,2.5,UN,,11.98,8.99,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,16714014101,NDC,,,facility,both,4,UN,,2.54,1.9,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,16714014101,NDC,,,facility,both,0.5,UN,,6.9,5.18,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 2 MG TABS,59962,CDM,250,RC,16714014101,NDC,,,facility,both,5,UN,,2.15,1.61,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL 100 MG TB24,60006,CDM,250,RC,47335085983,NDC,,,facility,both,1,UN,,10.7,8.02,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL 100 MG TB24,60006,CDM,250,RC,68180069706,NDC,,,facility,both,1,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TABS,60048,CDM,250,RC,904663961,NDC,,,facility,both,0.5,UN,,7.38,5.53,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TABS,60048,CDM,250,RC,904663961,NDC,,,facility,both,1.5,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TABS,60048,CDM,250,RC,904663961,NDC,,,facility,both,1,UN,,8.24,6.18,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TABS,60048,CDM,250,RC,904663961,NDC,,,facility,both,3,UN,,3.57,2.67,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TABS,60048,CDM,250,RC,904663961,NDC,,,facility,both,2,UN,,4.85,3.64,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 50 MG TABS,60048,CDM,250,RC,904663961,NDC,,,facility,both,4,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS SOLR,60053,CDM,636,RC,J7187,HCPCS,63833061502,NDC,facility,both,1,UN,,2.62,1.97,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIHEMOPHILIC FACTOR-VWF SOLR,60054,CDM,636,RC,J7187,HCPCS,63833061602,NDC,facility,both,1,UN,,2.07,1.55,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS SOLR,60055,CDM,636,RC,J7187,HCPCS,63833061702,NDC,facility,both,1,UN,,2.56,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS SOLR,60055,CDM,636,RC,J7187,HCPCS,63833062701,NDC,facility,both,1,UN,,2.56,1.92,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNITS/ML SOLN,60069,CDM,637,RC,J1815,HCPCS,169368712,NDC,facility,both,5,UN,,16.93,12.7,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE 2 MCG/ML-0.2% 0.2-0.2-0.9 MG/100ML-% SOLN,6010140,CDM,636,RC,J7999,HCPCS,70092110836,NDC,facility,both,100,ML,,149.4,112.05,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 12.5%,6010146,CDM,250,RC,990793002,NDC,,,facility,both,250,ML,,23.15,17.36,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,6010167,CDM,636,RC,J1644,HCPCS,409315020,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,6010167,CDM,636,RC,J1644,HCPCS,63323051877,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE (ROCEPHIN) 40 MG/ML IN NS SOLUTION 40 MG/ML,6010174,CDM,636,RC,J0696,HCPCS,409733503,NDC,facility,both,250,ME,,8.32,6.24,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE (ROCEPHIN) 40 MG/ML IN NS SOLUTION 40 MG/ML,6010174,CDM,636,RC,J0696,HCPCS,409733211,NDC,facility,both,250,ME,,11.5,8.62,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE (ROCEPHIN) 40 MG/ML IN NS SOLUTION 40 MG/ML,6010174,CDM,636,RC,J0696,HCPCS,781320895,NDC,facility,both,250,ME,,14.72,11.04,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE 25 MG/ML (P/F) SOLN,6010178,CDM,636,RC,J9260,HCPCS,143951910,NDC,facility,both,5,ME,,0.99,0.74,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 50 UNITS/ML 50 UNITS/ML SOLN,6010192,CDM,636,RC,J1644,HCPCS,409315020,NDC,facility,both,1000,UN,,2.66,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE,6010217,CDM,250,RC,67457083902,NDC,,,facility,both,2,ML,,25.6,19.2,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE,6010217,CDM,250,RC,67457083902,NDC,,,facility,both,1.5,ML,,25.6,19.2,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE,6010217,CDM,250,RC,67457083902,NDC,,,facility,both,5,ML,,8.82,6.61,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 50 MCG/ACT SUSP 16 G BOTTLE,60192,CDM,250,RC,MHS1GM,HCPCS,54327099,NDC,facility,both,1,GM,,0.93,0.7,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 50 MCG/ACT SUSP 16 G BOTTLE,60192,CDM,250,RC,MHS1GM,HCPCS,60432026415,NDC,facility,both,1,GM,,0.8,0.6,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE-SODIUM PHOSPHATE 280-160-250 MG PACK,60228,CDM,250,RC,60258000601,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE-SODIUM PHOSPHATE 280-160-250 MG PACK,60228,CDM,250,RC,60258000601,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE 500 MG TB12,60231,CDM,250,RC,60687054921,NDC,,,facility,both,2,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE 500 MG TB12,60231,CDM,250,RC,50228042360,NDC,,,facility,both,2,UN,,5.28,3.96,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE 500 MG TB12,60231,CDM,250,RC,60687054921,NDC,,,facility,both,1,UN,,10.55,7.91,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE 500 MG TB12,60231,CDM,250,RC,50228042360,NDC,,,facility,both,1,UN,,9.1,6.82,,,,,,,,,,Gross Charge Type: Pharmacy
SELEGILINE 6 MG/24HR PT24,60469,CDM,250,RC,49502090001,NDC,,,facility,both,2,UN,,102.92,77.19,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG/5ML (10%) SUSR,60585,CDM,250,RC,MHS5ML,HCPCS,50419077301,NDC,facility,both,5,ML,,19.65,14.74,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 5 MG/ML SOLR 1 EACH VIAL,60595,CDM,636,RC,J0894,HCPCS,143938501,NDC,facility,both,1,ME,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 5 MG/ML SOLR 1 EACH VIAL,60595,CDM,636,RC,J0894,HCPCS,72205003101,NDC,facility,both,1,ME,,6.69,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG/9 HR PTCH,60624,CDM,250,RC,378826016,NDC,,,facility,both,1,UN,,26.8,20.1,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 10 MG/9 HR PTCH,60624,CDM,250,RC,378826093,NDC,,,facility,both,1,UN,,26.85,20.14,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 380 MG IM SUSR,60758,CDM,65757030001,NDC,,,,,facility,both,1,EA,,8.72,6.54,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 380 MG IM SUSR,60758,CDM,65757030001,NDC,,,,,facility,both,1,EA,,65,48.75,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 380 MG SUSR,60758,CDM,636,RC,J2315,HCPCS,65757030001,NDC,facility,both,1,ME,,9.03,6.77,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 600 MG CAPS,60772,CDM,250,RC,54629409760,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 600 MG CAPS,60772,CDM,250,RC,54629409760,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE HUMAN 150 UNIT/ML SOLN,60775,CDM,636,RC,J3473,HCPCS,18657011704,NDC,facility,both,1,UN,,1.29,0.97,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE HUMAN 150 UNIT/ML SOLN 1 ML VIAL,60775,CDM,636,RC,J3473,HCPCS,18657011704,NDC,facility,both,1,UN,,4.11,3.08,,,,,,,,,,Gross Charge Type: Pharmacy
VARENICLINE 0.5 MG TABS,60787,CDM,250,RC,49884015576,NDC,,,facility,both,2,UN,,14.78,11.08,,,,,,,,,,Gross Charge Type: Pharmacy
VARENICLINE 0.5 MG TABS,60787,CDM,250,RC,49884015576,NDC,,,facility,both,1,UN,,19.4,14.55,,,,,,,,,,Gross Charge Type: Pharmacy
RASAGILINE 0.5 MG TABS,60790,CDM,250,RC,16714077001,NDC,,,facility,both,1,UN,,16.15,12.11,,,,,,,,,,Gross Charge Type: Pharmacy
RASAGILINE 0.5 MG TABS,60790,CDM,250,RC,16714077001,NDC,,,facility,both,2,UN,,11.7,8.78,,,,,,,,,,Gross Charge Type: Pharmacy
RASAGILINE 1 MG TABS,60791,CDM,250,RC,16714077101,NDC,,,facility,both,0.5,UN,,14.05,10.54,,,,,,,,,,Gross Charge Type: Pharmacy
RASAGILINE 1 MG TABS,60791,CDM,250,RC,16714077101,NDC,,,facility,both,1,UN,,19.55,14.66,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGEST-ETH ESTRAD 91-DAY 0.15-0.03 &0.01 MG TABS,60988,CDM,250,RC,93313482,NDC,,,facility,both,1,UN,,11.95,8.96,,,,,,,,,,Gross Charge Type: Pharmacy
ETONOGESTREL 68 MG IMPL,61113,CDM,636,RC,J7307,HCPCS,78206014501,NDC,facility,both,1,EA,,2541.45,1906.09,,,,,,,,,,Gross Charge Type: Pharmacy
ETONOGESTREL 68 MG SC IMPL,61113,CDM,78206014501,NDC,,,,,facility,both,1,EA,,1983.37,1487.53,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML SOLN,61292,CDM,636,RC,J1953,HCPCS,67457079005,NDC,facility,both,10,ME,,0.82,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML SOLN 5 ML VIAL,61292,CDM,636,RC,J1953,HCPCS,67457079005,NDC,facility,both,10,ME,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML SOLN,61526,CDM,250,RC,MHS1ML,HCPCS,25021060203,NDC,facility,both,1,ML,,8.75,6.56,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML SOLN,61526,CDM,250,RC,MHS1ML,HCPCS,63323040603,NDC,facility,both,1,ML,,21.1,15.82,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE 20 MG/ML SOLN,61527,CDM,636,RC,J0706,HCPCS,55150018703,NDC,facility,both,5,ME,,9.11,6.83,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE 20 MG/ML SOLN,61527,CDM,636,RC,J0706,HCPCS,72485010401,NDC,facility,both,5,ME,,11.67,8.75,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.5 MG/5ML SOLN,6303,CDM,636,RC,J8540,HCPCS,54317763,NDC,facility,both,0.25,ME,,2.07,1.55,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG TABS,6307,CDM,636,RC,J8540,HCPCS,54817425,NDC,facility,both,0.25,ME,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 2 MG TABS,6309,CDM,636,RC,J8540,HCPCS,54418325,NDC,facility,both,0.25,ME,,0.47,0.36,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 2 MG TABS,6309,CDM,636,RC,J8540,HCPCS,54817625,NDC,facility,both,0.25,ME,,0.76,0.57,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG OR TABS,6310,CDM,54817525,NDC,,,,,facility,both,0.25,EA,,0.7,0.52,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG TABS,6310,CDM,636,RC,J8540,HCPCS,54817525,NDC,facility,both,0.25,ME,,0.4,0.3,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML SOLN,6314,CDM,636,RC,J1100,HCPCS,70069002125,NDC,facility,both,1,ME,,4.93,3.7,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML SOLN,6314,CDM,636,RC,J1100,HCPCS,55150030425,NDC,facility,both,1,ME,,5.14,3.86,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML SOLN,6314,CDM,636,RC,J1100,HCPCS,641036725,NDC,facility,both,1,ME,,3.41,2.56,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML SOLN 1 ML VIAL,6314,CDM,636,RC,J1100,HCPCS,70069002125,NDC,facility,both,1,ME,,2.07,1.55,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML SOLN 1 ML VIAL,6314,CDM,636,RC,J1100,HCPCS,641036725,NDC,facility,both,1,ME,,1.74,1.31,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN,6314,CDM,67457042010,NDC,,,,,facility,both,1,ML,,1.95,1.46,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN,6314,CDM,641036725,NDC,,,,,facility,both,1,ML,,1.3,0.98,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,6316,CDM,636,RC,J1100,HCPCS,67457042312,NDC,facility,both,1,ME,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,6316,CDM,636,RC,J1100,HCPCS,72572012001,NDC,facility,both,1,ME,,5.43,4.07,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,6316,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,both,1,ME,,9.64,7.23,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,6316,CDM,636,RC,J1100,HCPCS,641614525,NDC,facility,both,1,ME,,5.49,4.11,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,6316,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,both,1,ME,,4.14,3.1,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,6316,CDM,636,RC,J1100,HCPCS,67457042254,NDC,facility,both,1,ME,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN,6316,CDM,636,RC,J1100,HCPCS,76045010610,NDC,facility,both,1,ME,,6.69,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN 1 ML VIAL,6316,CDM,636,RC,J1100,HCPCS,67457042312,NDC,facility,both,1,ME,,2.13,1.6,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML SOLN 5 ML VIAL,6316,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,both,1,ME,,4.91,3.68,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN,6316,CDM,67457042312,NDC,,,,,facility,both,1,ML,,4.19,3.15,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN,6316,CDM,72572012001,NDC,,,,,facility,both,1,ML,,7.99,5.99,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN,6316,CDM,67457042300,NDC,,,,,facility,both,1,ML,,1.3,0.98,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % SOLN 5 ML BOTTLE,6319,CDM,250,RC,MHS1ML,HCPCS,24208072002,NDC,facility,both,1,ML,,21.33,16,,,,,,,,,,Gross Charge Type: Pharmacy
Noncdm Charge Record Medical Supplies,63600000S1_Q4196_278,CDM,278,RC,Q4196,HCPCS,,,facility,both,,,,1417.5,1063.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
DEXTROSE 10 % SOLN,6380,CDM,250,RC,MHS1ML,HCPCS,990793002,NDC,facility,both,1,ML,,0.23,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10 % SOLN,6380,CDM,250,RC,MHS1ML,HCPCS,338002302,NDC,facility,both,1,ML,,0.21,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10 % SOLN,6380,CDM,250,RC,MHS1ML,HCPCS,338002304,NDC,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 10 % SOLN 1,000 ML FLEX CONT",6380,CDM,250,RC,MHS1ML,HCPCS,338002304,NDC,facility,both,1,ML,,0.05,0.04,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10 % SOLN 250 ML FLEX CONT,6380,CDM,250,RC,MHS1ML,HCPCS,990793002,NDC,facility,both,1,ML,,0.23,0.17,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10 % SOLN 250 ML FLEX CONT,6380,CDM,250,RC,MHS1ML,HCPCS,338002302,NDC,facility,both,1,ML,,0.19,0.14,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10 % SOLN 250 ML FLEX CONT,6380,CDM,250,RC,MHS1ML,HCPCS,338001702,NDC,facility,both,1,ML,,0.2,0.15,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 25 % 250 MG/ML SOLN,6384,CDM,250,RC,409177510,NDC,,,facility,both,40,ML,,30.02,22.52,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7060,HCPCS,338001703,NDC,facility,both,500,ML,,15.81,11.86,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7070,HCPCS,264751000,NDC,facility,both,500,ML,,21.6,16.2,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7060,HCPCS,338001718,NDC,facility,both,500,ML,,16.15,12.11,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7060,HCPCS,990792337,NDC,facility,both,500,ML,,16.15,12.11,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7070,HCPCS,338001704,NDC,facility,both,500,ML,,17.38,13.03,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7060,HCPCS,990792209,NDC,facility,both,500,ML,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7070,HCPCS,990792209,NDC,facility,both,500,ML,,23.7,17.78,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7060,HCPCS,338001704,NDC,facility,both,500,ML,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7060,HCPCS,990792202,NDC,facility,both,500,ML,,23.15,17.36,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7060,HCPCS,338001711,NDC,facility,both,500,ML,,9.3,6.98,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN,6388,CDM,636,RC,J7060,HCPCS,338001702,NDC,facility,both,500,ML,,16.35,12.26,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT",6388,CDM,636,RC,J7070,HCPCS,990792209,NDC,facility,both,500,ML,,23.7,17.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT",6388,CDM,636,RC,J7060,HCPCS,990792209,NDC,facility,both,500,ML,,11.85,8.89,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT",6388,CDM,636,RC,J7060,HCPCS,338001704,NDC,facility,both,500,ML,,8.7,6.52,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 5 % SOLN 1,000 ML FLEX CONT",6388,CDM,636,RC,J7070,HCPCS,338001704,NDC,facility,both,500,ML,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 100 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,338001718,NDC,facility,both,500,ML,,16.12,12.09,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 100 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,990792337,NDC,facility,both,500,ML,,16.16,12.12,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 100 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,264151032,NDC,facility,both,500,ML,,17.6,13.2,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 150 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,990792261,NDC,facility,both,500,ML,,22.95,17.21,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 250 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,264751020,NDC,facility,both,500,ML,,18.95,14.21,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 250 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,990792202,NDC,facility,both,500,ML,,23.15,17.36,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 250 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,338001702,NDC,facility,both,500,ML,,16.3,12.22,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 50 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,338001711,NDC,facility,both,500,ML,,15.09,11.32,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 50 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,990792336,NDC,facility,both,500,ML,,16.05,12.04,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 500 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,338001703,NDC,facility,both,500,ML,,16.31,12.23,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 500 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,264751010,NDC,facility,both,500,ML,,19.5,14.62,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5 % SOLN 500 ML FLEX CONT,6388,CDM,636,RC,J7060,HCPCS,990792203,NDC,facility,both,500,ML,,22.65,16.99,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50 % SOLN,6389,CDM,250,RC,MHS250ML,HCPCS,409751716,NDC,facility,both,250,ML,,65.45,49.09,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50 % SOLN,6389,CDM,250,RC,MHS250ML,HCPCS,76329330201,NDC,facility,both,250,ML,,66.3,49.73,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50 % SOLN,6389,CDM,250,RC,MHS250ML,HCPCS,70092147550,NDC,facility,both,250,ML,,73.86,55.4,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50 % SOLN,6389,CDM,250,RC,MHS250ML,HCPCS,409490234,NDC,facility,both,250,ML,,66.14,49.61,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50 % SOLN 50 ML SYRINGE,6389,CDM,250,RC,MHS250ML,HCPCS,409751716,NDC,facility,both,250,ML,,97.19,72.89,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50 % SOLN 50 ML SYRINGE,6389,CDM,250,RC,MHS250ML,HCPCS,70092147550,NDC,facility,both,250,ML,,134.3,100.73,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50 % SOLN 50 ML SYRINGE,6389,CDM,250,RC,MHS250ML,HCPCS,409490234,NDC,facility,both,250,ML,,93.79,70.34,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50 % SOLN 50 ML SYRINGE,6389,CDM,250,RC,MHS250ML,HCPCS,76329330201,NDC,facility,both,250,ML,,77.85,58.39,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50 % SOLN 50 ML VIAL,6389,CDM,250,RC,MHS250ML,HCPCS,409664802,NDC,facility,both,250,ML,,64.65,48.49,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,16.217,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,39.086,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,23.571,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,9.6,ML,,47.35,35.51,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,17.143,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,171.43,ML,,49.2,36.9,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,48.343,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,192.857,ML,,49.45,37.09,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,350,ML,,51.05,38.29,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,21.497,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,28.286,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,12.823,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,67.714,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,16.971,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,28.663,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,17.726,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,70.286,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,33.429,ML,,47.65,35.74,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,19.234,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,24.514,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,37.029,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,307.143,ML,,50.65,37.99,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,60.857,ML,,47.95,35.96,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,12.343,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,42.994,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,18,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,27,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,14.057,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,12.686,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,66.429,ML,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,63.429,ML,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,35.442,ML,,47.65,35.74,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,42.514,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,45,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,10.56,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,13.371,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,25.371,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,16.457,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,46.629,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,68.503,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,221.429,ML,,49.75,37.31,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,242.857,ML,,49.95,37.46,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,19.543,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,128.571,ML,,48.7,36.52,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,61.714,ML,,47.95,35.96,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,30.171,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,29.623,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,20.743,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,150,ML,,48.95,36.71,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,15,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,25.646,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,13.2,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,10.286,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,28.714,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,19.2,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,385.714,ML,,51.45,38.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,18.857,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,18.429,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,46.286,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,42.24,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,44.743,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,16.114,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,26.4,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,371.429,ML,,51.3,38.48,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,54.857,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,17.829,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,35.438,ML,,47.65,35.74,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,69.857,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,36.686,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,22.629,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,16.8,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,39.429,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,57.326,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,24.343,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,21.12,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,157.143,ML,,49.05,36.79,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,25.92,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,34.286,ML,,47.65,35.74,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,49.286,ML,,47.85,35.89,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,20.914,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,26.777,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,54,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,14.743,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,185.714,ML,,49.35,37.01,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,31.286,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,60,ML,,47.95,35.96,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,21.874,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,31.2,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,37.714,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,15.771,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,48,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,11.691,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,46.714,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,471.429,ML,,52.35,39.26,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,9.943,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,41.486,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,28.389,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,35.75,ML,,47.65,35.74,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,74.143,ML,,48.1,36.08,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,75.714,ML,,48.15,36.11,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,314.286,ML,,50.7,38.02,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,6.857,ML,,47.35,35.51,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,42.429,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,271.429,ML,,50.25,37.69,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,19.286,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,607.143,ML,,53.75,40.31,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,364.286,ML,,51.2,38.4,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,52.457,ML,,47.85,35.89,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,27.154,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,56.571,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,35.657,ML,,47.65,35.74,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,22.286,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,13.714,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,24.137,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,20.571,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,15.84,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,24.429,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,135.714,ML,,48.8,36.6,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,24.891,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,285.714,ML,,50.4,37.8,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,16.714,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,24.686,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,278.571,ML,,50.35,37.76,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,47.657,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,205.714,ML,,49.55,37.16,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,18.103,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,25.714,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,342.857,ML,,51,38.25,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,19.886,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,51.857,ML,,47.85,35.89,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,10.937,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,13.286,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,171.429,ML,,49.2,36.9,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,414.286,ML,,51.75,38.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,21.943,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,20.366,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,39.857,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,321.429,ML,,50.8,38.1,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,107.143,ML,,48.5,36.38,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,335.714,ML,,50.95,38.21,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,15.086,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,24.754,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,26.057,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,17.486,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,17.424,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,228.571,ML,,49.8,37.35,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,571.429,ML,,53.4,40.05,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,23.383,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,55.886,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,24,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,57.086,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,142.857,ML,,48.9,36.68,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,442.857,ML,,52.05,39.04,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,22.971,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,557.143,ML,,53.25,39.94,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,15.429,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,500,ML,,52.65,39.49,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,27.429,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,12,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,15.463,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,22.714,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,29.417,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,48.686,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,31.543,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,57.703,ML,,47.9,35.92,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,43.886,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,65.143,ML,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,257.143,ML,,50.1,37.58,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,19.714,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,457.143,ML,,52.2,39.15,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,8.229,ML,,47.35,35.51,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,21.6,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,18.514,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,66,ML,,48,36,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,29.143,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,29.486,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,378.571,ML,,51.35,38.51,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,48.429,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,250,ML,,50.05,37.54,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,114.286,ML,,48.55,36.41,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,535.714,ML,,53,39.75,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,61.286,ML,,47.95,35.96,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,30.857,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,23.314,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,20.229,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,66.857,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,30,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,300,ML,,50.55,37.91,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,21.257,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,214.286,ML,,49.65,37.24,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,21.429,ML,,47.5,35.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,24.48,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,18.171,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,36.343,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,25.029,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,28.114,ML,,47.6,35.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,328.571,ML,,50.85,38.14,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,44.126,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,67.286,ML,,48.05,36.04,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,36,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,39.977,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,47.314,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,41.863,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,392.857,ML,,51.5,38.62,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,357.143,ML,,51.15,38.36,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,38.4,ML,,47.7,35.78,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,14.4,ML,,47.45,35.59,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,44.643,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,23.657,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,400,ML,,51.6,38.7,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,42.857,ML,,47.75,35.81,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,13.954,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,48.137,ML,,47.8,35.85,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,464.286,ML,,52.25,39.19,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,200,ML,,49.5,37.12,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,23.04,ML,,47.55,35.66,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,428.571,ML,,51.9,38.92,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,13.029,ML,,47.4,35.55,,,,,,,,,,Gross Charge Type: Pharmacy
"DEXTROSE 70 % SOLN 2,000 ML FLEX CONT",6392,CDM,250,RC,990712007,NDC,,,facility,both,178.571,ML,,49.25,36.94,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE 5 MG TABS,6460,CDM,250,RC,50268012711,NDC,,,facility,both,1,UN,,10.2,7.65,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE 5 MG TABS,6460,CDM,250,RC,29300012601,NDC,,,facility,both,2,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE 5 MG TABS,6460,CDM,250,RC,50268012711,NDC,,,facility,both,0.5,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE 5 MG TABS,6460,CDM,250,RC,50268012711,NDC,,,facility,both,2,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE 5 MG TABS,6460,CDM,250,RC,29300012601,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG TABS,6461,CDM,250,RC,29300018901,NDC,,,facility,both,1,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG TABS,6462,CDM,250,RC,29300018801,NDC,,,facility,both,1,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50268075615,NDC,,,facility,both,2.5,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50268075615,NDC,,,facility,both,3,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50268075615,NDC,,,facility,both,1,UN,,7.91,5.93,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50268075615,NDC,,,facility,both,2,UN,,4.52,3.39,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50111091701,NDC,,,facility,both,2,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50111091701,NDC,,,facility,both,1,UN,,7.2,5.4,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50268075615,NDC,,,facility,both,4,UN,,2.61,1.96,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,68084053901,NDC,,,facility,both,1,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50111091701,NDC,,,facility,both,1.5,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50268075615,NDC,,,facility,both,1.5,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50268075615,NDC,,,facility,both,0.5,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,50111091701,NDC,,,facility,both,0.5,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 20 MG TABS,6478,CDM,250,RC,68084053901,NDC,,,facility,both,0.5,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 100 MG TABS,6501,CDM,250,RC,50268075715,NDC,,,facility,both,1.5,UN,,4.4,3.3,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 100 MG TABS,6501,CDM,250,RC,50268075715,NDC,,,facility,both,2,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 100 MG TABS,6501,CDM,250,RC,50111091801,NDC,,,facility,both,2,UN,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 100 MG TABS,6501,CDM,250,RC,50111091801,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 100 MG TABS,6501,CDM,250,RC,50268075715,NDC,,,facility,both,0.5,UN,,6.96,5.22,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 100 MG TABS,6501,CDM,250,RC,50268075715,NDC,,,facility,both,1,UN,,8.25,6.19,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML SOLN,6503,CDM,636,RC,J3360,HCPCS,409127332,NDC,facility,both,5,ME,,50.03,37.52,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML SOLN,6503,CDM,636,RC,J3360,HCPCS,641624410,NDC,facility,both,5,ME,,45.82,34.36,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML SOLN,6503,CDM,636,RC,J3360,HCPCS,69339013634,NDC,facility,both,5,ME,,43.93,32.94,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 10 MG TABS,6505,CDM,250,RC,51079028620,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 10 MG TABS,6505,CDM,250,RC,172392760,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 10 MG TABS,6505,CDM,250,RC,172392760,NDC,,,facility,both,1,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 10 MG TABS,6505,CDM,250,RC,51079028620,NDC,,,facility,both,2,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 10 MG TABS,6505,CDM,250,RC,51079028620,NDC,,,facility,both,3,UN,,1.88,1.41,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 10 MG TABS,6505,CDM,250,RC,51079028620,NDC,,,facility,both,1,UN,,5.32,3.99,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 2 MG TABS,6506,CDM,250,RC,51079028420,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 2 MG TABS,6506,CDM,250,RC,51079028420,NDC,,,facility,both,1,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 2 MG TABS,6506,CDM,250,RC,51079028420,NDC,,,facility,both,2,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 2 MG TABS,6506,CDM,250,RC,51079028420,NDC,,,facility,both,2.5,UN,,1.85,1.39,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 2 MG TABS,6506,CDM,250,RC,51079028420,NDC,,,facility,both,0.25,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG TABS,6507,CDM,250,RC,51079028520,NDC,,,facility,both,4,UN,,1.41,1.06,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG TABS,6507,CDM,250,RC,172392660,NDC,,,facility,both,0.5,UN,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG TABS,6507,CDM,250,RC,51079028520,NDC,,,facility,both,1,UN,,5.29,3.97,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG TABS,6507,CDM,250,RC,172392660,NDC,,,facility,both,2,UN,,2.65,1.99,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG TABS,6507,CDM,250,RC,172392660,NDC,,,facility,both,1,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG TABS,6507,CDM,250,RC,51079028520,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG TABS,6507,CDM,250,RC,172392660,NDC,,,facility,both,3,UN,,1.77,1.32,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG TABS,6507,CDM,250,RC,51079028520,NDC,,,facility,both,0.05,UN,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG TABS,6507,CDM,250,RC,51079028520,NDC,,,facility,both,2,UN,,2.72,2.04,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 5 MG TABS,6511,CDM,250,RC,50268075415,NDC,,,facility,both,4,UN,,2.49,1.87,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 5 MG TABS,6511,CDM,250,RC,50268075415,NDC,,,facility,both,1,UN,,7.7,5.78,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 5 MG TABS,6511,CDM,250,RC,50268075415,NDC,,,facility,both,10,UN,,1.32,0.99,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 5 MG TABS,6511,CDM,250,RC,50268075415,NDC,,,facility,both,2,UN,,4.16,3.12,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE 5 MG TABS,6511,CDM,250,RC,50268075415,NDC,,,facility,both,3,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 2 % SUSP,6518,CDM,250,RC,32909074103,NDC,,,facility,both,450,ML,,11.3,8.48,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 2 % SUSP,6518,CDM,250,RC,32909074103,NDC,,,facility,both,900,ML,,8.28,6.21,,,,,,,,,,Gross Charge Type: Pharmacy
BARIUM SULFATE 2 % SUSP,6518,CDM,250,RC,32909074103,NDC,,,facility,both,1800,ML,,6.59,4.94,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM SOLR,6527,CDM,636,RC,J2543,HCPCS,409339004,NDC,facility,both,1.125,GM,,18.1,13.58,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM SOLR 1 EACH VIAL,6527,CDM,636,RC,J2543,HCPCS,64679001201,NDC,facility,both,1.125,GM,,14.51,10.88,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM SOLR 1 EACH VIAL,6527,CDM,636,RC,J2543,HCPCS,781311495,NDC,facility,both,1.125,GM,,14.41,10.81,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM SOLR 1 EACH VIAL,6527,CDM,636,RC,J2543,HCPCS,60505615904,NDC,facility,both,1.125,GM,,18.31,13.73,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM SOLR 1 EACH VIAL,6527,CDM,636,RC,J2543,HCPCS,409339004,NDC,facility,both,1.125,GM,,18.21,13.65,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM SOLR 1 EACH VIAL,6527,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,both,1.125,GM,,13.18,9.88,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM 3.375 SOLR,6528,CDM,636,RC,J2543,HCPCS,781311395,NDC,facility,both,1.125,GM,,16.48,12.36,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM 3.375 SOLR,6528,CDM,636,RC,J2543,HCPCS,409338513,NDC,facility,both,1.125,GM,,21.6,16.2,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM 3.375 SOLR 1 EACH VIAL,6528,CDM,636,RC,J2543,HCPCS,55150012030,NDC,facility,both,1.125,GM,,14.8,11.1,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM 3.375 SOLR 1 EACH VIAL,6528,CDM,636,RC,J2543,HCPCS,72485040301,NDC,facility,both,1.125,GM,,15.5,11.62,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM 3.375 SOLR 1 EACH VIAL,6528,CDM,636,RC,J2543,HCPCS,60505615704,NDC,facility,both,1.125,GM,,22.87,17.15,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM 3.375 SOLR 1 EACH VIAL,6528,CDM,636,RC,J2543,HCPCS,409338513,NDC,facility,both,1.125,GM,,21.6,16.2,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM 3.375 SOLR 1 EACH VIAL,6528,CDM,636,RC,J2543,HCPCS,781311395,NDC,facility,both,1.125,GM,,16.5,12.37,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM SOLR 1 EACH VIAL,6533,CDM,636,RC,J2543,HCPCS,781311095,NDC,facility,both,1.125,GM,,22.1,16.58,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM SOLR 1 EACH VIAL,6533,CDM,636,RC,J2543,HCPCS,409338302,NDC,facility,both,1.125,GM,,34.02,25.52,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM SOLR 1 EACH VIAL,6533,CDM,636,RC,J2543,HCPCS,64679003401,NDC,facility,both,1.125,GM,,21.42,16.07,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS,6538,CDM,250,RC,60687060201,NDC,,,facility,both,2,UN,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS,6538,CDM,250,RC,904666761,NDC,,,facility,both,1,UN,,6.84,5.13,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS,6538,CDM,250,RC,904666761,NDC,,,facility,both,3,UN,,2.9,2.18,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS,6538,CDM,250,RC,904666761,NDC,,,facility,both,0.25,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS,6538,CDM,250,RC,60687060201,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS,6538,CDM,250,RC,904666761,NDC,,,facility,both,0.75,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS,6538,CDM,250,RC,904666761,NDC,,,facility,both,3.75,UN,,2.25,1.69,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS,6538,CDM,250,RC,904666761,NDC,,,facility,both,2,UN,,4.05,3.04,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS,6538,CDM,250,RC,60687060201,NDC,,,facility,both,3,UN,,2.97,2.22,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG CAPS 100 EACH BOX,6538,CDM,250,RC,904666761,NDC,,,facility,both,1,UN,,1.05,0.79,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,68084076201,NDC,,,facility,both,3,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,68084076201,NDC,,,facility,both,1,UN,,6.69,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,16714066201,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,60687059101,NDC,,,facility,both,0.6667,UN,,0.6,0.45,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,0.333333333,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,63739090310,NDC,,,facility,both,3,UN,,2.82,2.11,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,2.6667,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,63739090310,NDC,,,facility,both,4,UN,,2.19,1.64,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,60687059101,NDC,,,facility,both,3,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,16714066201,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,1.6667,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,60687059101,NDC,,,facility,both,1,UN,,6.59,4.94,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,60687059101,NDC,,,facility,both,2,UN,,3.76,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,0.6667,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,2.666666667,UN,,2.75,2.06,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,0.666666667,UN,,6.6,4.95,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,63739090310,NDC,,,facility,both,2,UN,,3.34,2.5,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,1.3333,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,68084076201,NDC,,,facility,both,2,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,2,UN,,3.63,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,68084076201,NDC,,,facility,both,4,UN,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,4,UN,,2.2,1.65,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,60687059101,NDC,,,facility,both,4,UN,,2.21,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,2.3333,UN,,0.65,0.49,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,1,UN,,6.34,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,904666661,NDC,,,facility,both,3,UN,,2.83,2.12,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS,6544,CDM,250,RC,63739090310,NDC,,,facility,both,1,UN,,6.77,5.08,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS 100 EACH BOX,6544,CDM,250,RC,904666661,NDC,,,facility,both,2,UN,,0.85,0.64,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG CAPS 100 EACH BOX,6544,CDM,250,RC,904666661,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,904666561,NDC,,,facility,both,2,UN,,3.57,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,904666561,NDC,,,facility,both,8,UN,,1.15,0.86,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,904666561,NDC,,,facility,both,3,UN,,2.53,1.9,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,904666561,NDC,,,facility,both,1,UN,,6.59,4.94,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,60687058011,NDC,,,facility,both,2,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,16714066101,NDC,,,facility,both,4,UN,,1.71,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,63739090210,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,904666561,NDC,,,facility,both,6,UN,,1.47,1.1,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,16714066101,NDC,,,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,60687058011,NDC,,,facility,both,1,UN,,6.8,5.1,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,904666561,NDC,,,facility,both,4,UN,,2.06,1.55,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS,6545,CDM,250,RC,16714066101,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG CAPS 100 EACH BOX,6545,CDM,250,RC,904666561,NDC,,,facility,both,2,UN,,3.58,2.68,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML SOLN,6548,CDM,636,RC,J0500,HCPCS,58914008052,NDC,facility,both,20,ME,,263.65,197.74,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG CAPS,6549,CDM,250,RC,904698761,NDC,,,facility,both,1,UN,,8.9,6.68,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG CAPS,6549,CDM,250,RC,527058601,NDC,,,facility,both,1,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG CAPS,6549,CDM,250,RC,60687036901,NDC,,,facility,both,1,UN,,8.55,6.41,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG CAPS,6549,CDM,250,RC,904698761,NDC,,,facility,both,2,UN,,5.08,3.81,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG CAPS,6549,CDM,250,RC,527058601,NDC,,,facility,both,2,UN,,3.82,2.87,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG CAPS,6549,CDM,250,RC,60687036901,NDC,,,facility,both,2,UN,,4.78,3.58,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG TABS,6560,CDM,250,RC,50458032001,NDC,,,facility,both,0.5,UN,,16,12,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,43547034106,NDC,,,facility,both,4,UN,,2.01,1.51,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,50458030001,NDC,,,facility,both,2,UN,,12.88,9.66,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,50458030001,NDC,,,facility,both,0.5,UN,,12.85,9.64,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,904736261,NDC,,,facility,both,3,UN,,3.33,2.5,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,904736261,NDC,,,facility,both,0.5,UN,,7.15,5.36,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,43547034106,NDC,,,facility,both,1,UN,,5.49,4.12,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,904736261,NDC,,,facility,both,1,UN,,8.25,6.19,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,904736261,NDC,,,facility,both,2,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,43547034106,NDC,,,facility,both,3,UN,,2.52,1.89,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,904736261,NDC,,,facility,both,4,UN,,2.69,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,50458030001,NDC,,,facility,both,1,UN,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG TABS,6562,CDM,250,RC,50458030001,NDC,,,facility,both,4,UN,,10.36,7.77,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE 1 MG/ML SOLN,6566,CDM,636,RC,J1250,HCPCS,409234631,NDC,facility,both,250,ME,,67.75,50.81,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE 1 MG/ML SOLN,6566,CDM,636,RC,J1250,HCPCS,338107302,NDC,facility,both,250,ME,,69.11,51.83,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE 1-5 MG/ML-% SOLN,6566,CDM,636,RC,J1250,HCPCS,338107302,NDC,facility,both,250,ME,,69.15,51.86,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE SOLR 1 EACH VIAL,66,CDM,636,RC,J9070,HCPCS,781324494,NDC,facility,both,5,ME,,191.13,143.35,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE SOLR 1 EACH VIAL,66,CDM,636,RC,J9075,HCPCS,781324494,NDC,facility,both,5,ME,,9.23,6.92,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 0.25 MG/ML SOLN,6617,CDM,636,RC,J1160,HCPCS,641141035,NDC,facility,both,0.5,ME,,34.8,26.1,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 0.25 MG/ML SOLN,6617,CDM,636,RC,J1160,HCPCS,781305995,NDC,facility,both,0.5,ME,,42.34,31.76,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG TABS,6619,CDM,250,RC,904592161,NDC,,,facility,both,4,UN,,4.31,3.23,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG TABS,6619,CDM,250,RC,904592161,NDC,,,facility,both,0.5,UN,,8.95,6.71,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG TABS,6619,CDM,250,RC,904592161,NDC,,,facility,both,2,UN,,6.38,4.78,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG TABS,6619,CDM,250,RC,904592161,NDC,,,facility,both,1.5,UN,,5.78,4.33,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG TABS,6619,CDM,250,RC,904592161,NDC,,,facility,both,1,UN,,10.3,7.72,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG TABS,6619,CDM,250,RC,16714059001,NDC,,,facility,both,1,UN,,8.5,6.38,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG TABS,6620,CDM,250,RC,904592261,NDC,,,facility,both,1,UN,,10.2,7.65,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,93031801,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,93031801,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,93031801,NDC,,,facility,both,1,UN,,6.65,4.99,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,93031801,NDC,,,facility,both,3,UN,,2.63,1.97,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,60687056201,NDC,,,facility,both,1,UN,,8.15,6.11,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,60687071701,NDC,,,facility,both,2,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,60687056201,NDC,,,facility,both,2,UN,,4.58,3.43,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,60687071701,NDC,,,facility,both,1,UN,,8.2,6.15,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,93031801,NDC,,,facility,both,1.5,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TABS,6671,CDM,250,RC,60687056201,NDC,,,facility,both,0.5,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TABS,6672,CDM,250,RC,93031901,NDC,,,facility,both,2,UN,,4.18,3.13,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TABS,6672,CDM,250,RC,93031901,NDC,,,facility,both,1,UN,,7.01,5.26,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TABS,6672,CDM,250,RC,93031901,NDC,,,facility,both,0.5,UN,,6.58,4.93,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TABS,6672,CDM,250,RC,93031901,NDC,,,facility,both,1.5,UN,,3.9,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
DIMENHYDRINATE 50 MG TABS,6693,CDM,250,RC,904205159,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) SOLN,66996,CDM,250,RC,MHS1ML,HCPCS,121494840,NDC,facility,both,1,ML,,0.9,0.67,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN 50 MG TABS,67132,CDM,250,RC,6011228,NDC,,,facility,both,0.5,UN,,24.07,18.05,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN 50 MG TABS,67132,CDM,250,RC,6011228,NDC,,,facility,both,1,UN,,38.31,28.73,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN 50 MG TABS,67132,CDM,250,RC,6011228,NDC,,,facility,both,2,UN,,33.05,24.79,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG SOLR 1 EACH VIAL,67264,CDM,636,RC,J2248,HCPCS,469321110,NDC,facility,both,1,ME,,5.42,4.06,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG SOLR 1 EACH VIAL,67264,CDM,636,RC,J2248,HCPCS,25021019110,NDC,facility,both,1,ME,,1.45,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 1 MG/ML SOLN,67289,CDM,250,RC,MHS1ML,HCPCS,121157610,NDC,facility,both,1,ML,,0.83,0.62,,,,,,,,,,Gross Charge Type: Pharmacy
PRESERVISION AREDS CAPS,67398,CDM,250,RC,24208053210,NDC,,,facility,both,2,UN,,4.36,3.27,,,,,,,,,,Gross Charge Type: Pharmacy
PRESERVISION AREDS CAPS,67398,CDM,250,RC,24208053210,NDC,,,facility,both,1,UN,,7.58,5.69,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 3 MG TB24,67637,CDM,250,RC,904693561,NDC,,,facility,both,1,UN,,28.63,21.47,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 3 MG TB24,67637,CDM,250,RC,60687045911,NDC,,,facility,both,2,UN,,28.05,21.04,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 3 MG TB24,67637,CDM,250,RC,60687045911,NDC,,,facility,both,1,UN,,33.35,25.01,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 3 MG TB24,67637,CDM,250,RC,904693561,NDC,,,facility,both,3,UN,,21.88,16.41,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 3 MG TB24,67637,CDM,250,RC,60687045911,NDC,,,facility,both,4,UN,,25.15,18.86,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 3 MG TB24,67637,CDM,250,RC,60687045911,NDC,,,facility,both,3,UN,,26.3,19.72,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 6 MG TB24,67638,CDM,250,RC,904693661,NDC,,,facility,both,1,UN,,28.55,21.41,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 6 MG TB24,67638,CDM,250,RC,904693661,NDC,,,facility,both,2,UN,,24.64,18.48,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE 9 MG TB24,67639,CDM,250,RC,904693761,NDC,,,facility,both,1,UN,,35,26.25,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML SOLN,6778,CDM,636,RC,J1200,HCPCS,76045010210,NDC,facility,both,50,ME,,30.66,22.99,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML SOLN,6778,CDM,636,RC,J1200,HCPCS,72485010125,NDC,facility,both,50,ME,,49.32,36.99,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML SOLN,6778,CDM,636,RC,J1200,HCPCS,641037625,NDC,facility,both,50,ME,,27.64,20.73,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML SOLN,6778,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,both,50,ME,,38.74,29.06,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML SOLN 1 ML VIAL,6778,CDM,636,RC,J1200,HCPCS,641037625,NDC,facility,both,50,ME,,9.71,7.28,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML SOLN 1 ML VIAL,6778,CDM,636,RC,J1200,HCPCS,72485010125,NDC,facility,both,50,ME,,59.34,44.51,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,6778,CDM,63323066401,NDC,,,,,facility,both,50,ML,,44.6,33.45,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,6778,CDM,641037625,NDC,,,,,facility,both,50,ML,,14.44,10.83,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAPS,6779,CDM,250,RC,904723761,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAPS,6779,CDM,250,RC,904723761,NDC,,,facility,both,3,UN,,2.22,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAPS,6779,CDM,250,RC,FAMRXNC,HCPCS,904723761,NDC,facility,both,1,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAPS,6779,CDM,250,RC,904723761,NDC,,,facility,both,1,UN,,6.25,4.68,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG CAPS,6780,CDM,250,RC,904205661,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG CAPS,6780,CDM,250,RC,904205661,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG CAPS,6780,CDM,250,RC,904530760,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5ML ELIX,6781,CDM,250,RC,MHS5ML,HCPCS,121048900,NDC,facility,both,5,ML,,8.36,6.27,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG TABS,6783,CDM,250,RC,904555159,NDC,,,facility,both,2,UN,,3.12,2.34,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML LIQD,6786,CDM,250,RC,MHS1ML,HCPCS,54319446,NDC,facility,both,1,ML,,2.94,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS,6787,CDM,250,RC,59762106101,NDC,,,facility,both,1,UN,,6.05,4.54,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS,6787,CDM,250,RC,59762106101,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS,6787,CDM,250,RC,406123601,NDC,,,facility,both,2,UN,,2.98,2.23,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS,6787,CDM,250,RC,406123601,NDC,,,facility,both,1,UN,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,680,CDM,250,RC,J7613,HCPCS,487950101,NDC,facility,both,1,ML,,12.25,9.19,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU,680,CDM,250,RC,MHS1ML,HCPCS,487950101,NDC,facility,both,1,ML,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL (2.5 MG/3ML) 0.083% NEBU 3 ML PLAS CONT,680,CDM,250,RC,MHS1ML,HCPCS,487950101,NDC,facility,both,1,ML,,0.39,0.29,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,680,CDM,487950101,NDC,,,,,facility,both,1,ML,,8.25,6.19,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,680,CDM,487950101,NDC,,,,,facility,both,1,ML,,30.1,22.58,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 1.2 GM TBEC,68059,CDM,250,RC,60687039795,NDC,,,facility,both,4,UN,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 1.2 GM TBEC,68059,CDM,250,RC,60687039795,NDC,,,facility,both,2,UN,,20.05,15.04,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL (5 MG/ML) 0.5% NEBU,681,CDM,250,RC,MHS0.5ML,HCPCS,487990130,NDC,facility,both,0.5,ML,,6.76,5.07,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL (5 MG/ML) 0.5% NEBU 1 EACH PLAS CONT,681,CDM,250,RC,MHS0.5ML,HCPCS,487990130,NDC,facility,both,0.5,ML,,1.11,0.83,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL (5 MG/ML) 0.5% NEBU 5 ML PLAS CONT,681,CDM,250,RC,MHS0.5ML,HCPCS,69374033005,NDC,facility,both,0.5,ML,,2.09,1.57,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG SUSR,68169,CDM,636,RC,J9025,HCPCS,781325394,NDC,facility,both,1,ME,,6.49,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG SUSR 1 EACH VIAL,68169,CDM,636,RC,J9025,HCPCS,71288011530,NDC,facility,both,1,ME,,1.49,1.12,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG SUSR 1 EACH VIAL,68169,CDM,636,RC,J9025,HCPCS,16729030610,NDC,facility,both,1,ME,,3.75,2.81,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG SUSR 1 EACH VIAL,68169,CDM,636,RC,J9025,HCPCS,143960601,NDC,facility,both,1,ME,,2.5,1.87,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG SUSR 1 EACH VIAL,68169,CDM,636,RC,J9025,HCPCS,781325394,NDC,facility,both,1,ME,,6.56,4.92,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG SUSR 1 EACH VIAL,68169,CDM,636,RC,J9025,HCPCS,781925394,NDC,facility,both,1,ME,,10.89,8.17,,,,,,,,,,Gross Charge Type: Pharmacy
Hc P1 Trauma Without Critical Care,6820000001,CDM,682,RC,,,,,facility,both,,,,6231.5,4673.62,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc P1 Trauma Without Critical Care,6820000001,CDM,682,RC,,,,,facility,both,,,,6231.5,4673.62,,,,,,,,,,"Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Hc P2 Trauma Without Critical Care,6820000002,CDM,682,RC,,,,,facility,both,,,,5665,4248.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P2 Trauma Without Critical Care,6820000002,CDM,682,RC,,,,,facility,both,,,,5665,4248.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P3 Trauma Without Critical Care,6820000003,CDM,682,RC,,,,,facility,both,,,,4950,3712.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P3 Trauma Without Critical Care,6820000003,CDM,682,RC,,,,,facility,both,,,,4950,3712.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P1 Trauma With Critical Care,682G039001,CDM,682,RC,G0390,HCPCS,,,facility,both,,,,7882,5911.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P1 Trauma With Critical Care,682G039001,CDM,682,RC,G0390,HCPCS,,,facility,both,,,,7882,5911.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P2 Trauma With Critical Care,682G039002,CDM,682,RC,G0390,HCPCS,,,facility,both,,,,7315,5486.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P2 Trauma With Critical Care,682G039002,CDM,682,RC,G0390,HCPCS,,,facility,both,,,,7315,5486.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc P3 Trauma With Critical Care,682G039003,CDM,682,RC,G0390,HCPCS,,,facility,both,,,,6600,4950,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc P3 Trauma With Critical Care,682G039003,CDM,682,RC,G0390,HCPCS,,,facility,both,,,,6600,4950,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
DISOPYRAMIDE 150 MG CAPS,6837,CDM,250,RC,93312901,NDC,,,facility,both,1,UN,,10.85,8.14,,,,,,,,,,Gross Charge Type: Pharmacy
DISULFIRAM 250 MG TABS,6851,CDM,250,RC,62135043190,NDC,,,facility,both,1,UN,,25.55,19.16,,,,,,,,,,Gross Charge Type: Pharmacy
DISULFIRAM 250 MG TABS,6851,CDM,250,RC,47781060730,NDC,,,facility,both,1,UN,,11,8.25,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG TBEC,6888,CDM,250,RC,62756079688,NDC,,,facility,both,1,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG TBEC,6888,CDM,250,RC,62756079688,NDC,,,facility,both,4,UN,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG TBEC,6889,CDM,250,RC,68084077601,NDC,,,facility,both,1,UN,,7.17,5.38,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG TBEC,6889,CDM,250,RC,68084077601,NDC,,,facility,both,4,UN,,2.4,1.8,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG TBEC,6889,CDM,250,RC,68084077601,NDC,,,facility,both,2,UN,,4.3,3.22,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG TBEC,6889,CDM,250,RC,68084077601,NDC,,,facility,both,3,UN,,3.03,2.27,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG TBEC,6890,CDM,250,RC,832712401,NDC,,,facility,both,4,UN,,2.55,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG TBEC,6890,CDM,250,RC,832712401,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG TBEC,6890,CDM,250,RC,904686161,NDC,,,facility,both,2,UN,,4.22,3.17,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG TBEC,6890,CDM,250,RC,832712401,NDC,,,facility,both,1,UN,,6.92,5.19,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG TBEC,6890,CDM,250,RC,832712401,NDC,,,facility,both,0.5,UN,,2.95,2.21,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG TBEC,6890,CDM,250,RC,832712401,NDC,,,facility,both,3,UN,,3.18,2.39,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG TBEC,6890,CDM,250,RC,832712401,NDC,,,facility,both,1.5,UN,,4.28,3.21,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG TBEC,6890,CDM,250,RC,904686161,NDC,,,facility,both,1,UN,,7.25,5.44,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG TBEC,6890,CDM,250,RC,832712401,NDC,,,facility,both,2.75,UN,,3.13,2.35,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG CAPS,6927,CDM,250,RC,904728060,NDC,,,facility,both,2,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG CAPS,6927,CDM,250,RC,904718361,NDC,,,facility,both,2,UN,,3.32,2.49,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG CAPS,6927,CDM,250,RC,904718361,NDC,,,facility,both,3,UN,,2.32,1.74,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG CAPS,6927,CDM,250,RC,904728060,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG CAPS,6927,CDM,250,RC,904718361,NDC,,,facility,both,1,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG CAPS,6927,CDM,250,RC,904718361,NDC,,,facility,both,4,UN,,1.81,1.36,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG CAPS,6927,CDM,250,RC,904728060,NDC,,,facility,both,3,UN,,2.1,1.58,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 250 MG CAPS,6928,CDM,250,RC,48433010101,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 250 MG CAPS,6928,CDM,250,RC,50268026815,NDC,,,facility,both,2,UN,,4.38,3.28,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 250 MG CAPS,6928,CDM,250,RC,50268026815,NDC,,,facility,both,1,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 250 MG CAPS,6928,CDM,250,RC,50268026815,NDC,,,facility,both,4,UN,,2.48,1.86,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 150 MG/15ML LIQD,6930,CDM,250,RC,MHS10ML,HCPCS,121187000,NDC,facility,both,10,ML,,9.52,7.14,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 150 MG/15ML LIQD,6930,CDM,250,RC,MHS10ML,HCPCS,121054410,NDC,facility,both,10,ML,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE 40 MG/ML SOLN 10 ML VIAL,6999,CDM,636,RC,J1265,HCPCS,409910420,NDC,facility,both,40,ME,,3.95,2.96,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE 40 MG/ML SOLN 10 ML VIAL,6999,CDM,636,RC,J1265,HCPCS,143925401,NDC,facility,both,40,ME,,3.91,2.93,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 10 MG CAPS,7035,CDM,250,RC,51079043620,NDC,,,facility,both,1,UN,,8.8,6.6,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 10 MG CAPS,7035,CDM,250,RC,51079043620,NDC,,,facility,both,3,UN,,3.7,2.78,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 10 MG CAPS,7035,CDM,250,RC,51079043620,NDC,,,facility,both,2,UN,,4.98,3.73,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 25 MG CAPS,7038,CDM,250,RC,904705361,NDC,,,facility,both,2,UN,,5.58,4.18,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 25 MG CAPS,7038,CDM,250,RC,51079043720,NDC,,,facility,both,4,UN,,3.38,2.53,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 25 MG CAPS,7038,CDM,250,RC,51079043720,NDC,,,facility,both,1,UN,,9.03,6.77,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 25 MG CAPS,7038,CDM,250,RC,51079043720,NDC,,,facility,both,2,UN,,5.35,4.01,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 25 MG CAPS,7038,CDM,250,RC,904705361,NDC,,,facility,both,1,UN,,9.4,7.05,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 25 MG CAPS,7038,CDM,250,RC,904705361,NDC,,,facility,both,6,UN,,2.88,2.16,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 50 MG CAPS,7039,CDM,250,RC,16714013401,NDC,,,facility,both,2,UN,,5.68,4.26,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 50 MG CAPS,7039,CDM,250,RC,51079043820,NDC,,,facility,both,4,UN,,3.89,2.92,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 50 MG CAPS,7039,CDM,250,RC,51079043820,NDC,,,facility,both,3,UN,,4.57,3.42,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 50 MG CAPS,7039,CDM,250,RC,51079043820,NDC,,,facility,both,1,UN,,9.02,6.76,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 50 MG CAPS,7039,CDM,250,RC,16714013401,NDC,,,facility,both,3,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 50 MG CAPS,7039,CDM,250,RC,51079043820,NDC,,,facility,both,2,UN,,5.9,4.42,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 50 MG CAPS,7039,CDM,250,RC,16714013401,NDC,,,facility,both,1,UN,,8.92,6.69,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML SOLN 25 ML VIAL,7047,CDM,636,RC,J9000,HCPCS,143908601,NDC,facility,both,10,ME,,14.85,11.14,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML SOLN 25 ML VIAL,7047,CDM,636,RC,J9000,HCPCS,69303220,NDC,facility,both,10,ME,,20.33,15.24,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML SOLN 25 ML VIAL,7047,CDM,636,RC,J9000,HCPCS,63323088330,NDC,facility,both,10,ME,,25.43,19.08,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML SOLN 5 ML VIAL,7047,CDM,636,RC,J9000,HCPCS,143908401,NDC,facility,both,10,ME,,21.73,16.3,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE SOLR,7063,CDM,250,RC,MHS100MG,HCPCS,63323013011,NDC,facility,both,100,ME,,66.9,50.18,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE SOLR 1 EACH VIAL,7063,CDM,250,RC,MHS100MG,HCPCS,16714064410,NDC,facility,both,100,ME,,88.85,66.64,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE SOLR 1 EACH VIAL,7063,CDM,250,RC,MHS100MG,HCPCS,67457043710,NDC,facility,both,100,ME,,91.95,68.97,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE SOLR 1 EACH VIAL,7063,CDM,250,RC,MHS1GM,HCPCS,67457043710,NDC,facility,both,100,ME,,92.3,69.22,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE SOLR 1 EACH VIAL,7063,CDM,250,RC,MHS100MG,HCPCS,63323013011,NDC,facility,both,100,ME,,91.85,68.89,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE SOLR 1 EACH VIAL,7063,CDM,250,RC,MHS1GM,HCPCS,63323013011,NDC,facility,both,100,ME,,91.85,68.89,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Phase 1 Recovery 15 Min,7100000001,CDM,710,RC,,,,,facility,both,,,,396,297,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phase 2 Recovery 15 Min,7100000002,CDM,710,RC,,,,,facility,both,,,,246,184.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
DROPERIDOL 2.5 MG/ML SOLN,7143,CDM,636,RC,J1790,HCPCS,517970225,NDC,facility,both,5,ME,,40.28,30.21,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE SOLR 1 EACH VIAL,72,CDM,636,RC,J9070,HCPCS,781323394,NDC,facility,both,5,ME,,192.99,144.75,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE SOLR 1 EACH VIAL,72,CDM,636,RC,J9074,HCPCS,781323394,NDC,facility,both,5,ME,,10.47,7.85,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Delivery Service,7200000001,CDM,720,RC,,,,,facility,both,,,,3472,2604,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Delivery Service Leve Ii,7200000002,CDM,720,RC,,,,,facility,both,,,,4283,3212.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Delivery Service Leve Iii,7200000003,CDM,720,RC,,,,,facility,both,,,,4754,3565.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Delivery Service Level Iv,7200000004,CDM,720,RC,,,,,facility,both,,,,4884,3663,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Undelivered Service Level Iii,7200000005,CDM,720,RC,,,,,facility,both,,,,239,179.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Undelivered Service Level Iv,7200000006,CDM,720,RC,,,,,facility,both,,,,301,225.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pre Op C-Sec,7200000007,CDM,720,RC,,,,,facility,both,,,,429,321.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Post Delivery 2.00 Hr,7200000008,CDM,720,RC,,,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Post Delivery Complication,7200000009,CDM,720,RC,,,,,facility,both,,,,505,378.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
CARVEDILOL 10 MG CP24,72563,CDM,250,RC,57664066383,NDC,,,facility,both,1,UN,,23.2,17.4,,,,,,,,,,Gross Charge Type: Pharmacy
"External Ecg Rec More Than 48Hr, Less Than 7D Recording",7309324201,CDM,730,RC,93242,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"External Ecg Rec More Than 7D, Less Than 15D Recording",7309324601,CDM,730,RC,93246,HCPCS,,,facility,both,,,,190,142.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Ekg Tracing Initial Prev Tc,730G040401,CDM,730,RC,G0404,HCPCS,,,facility,both,,,,29,21.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Electroencephalogram W/Rec Awake & Drowsy,7409581601,CDM,740,RC,95816,HCPCS,,,facility,both,,,,1174,880.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Electroencephalogram W/Rec Awake & Asleep,7409581901,CDM,740,RC,95819,HCPCS,,,facility,both,,,,1142,856.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Somatosensory Test Upr & Lwr,7409593801,CDM,740,RC,95938,HCPCS,,,facility,both,,,,1662,1246.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Surgical Monitoring  Per 15Min,7409594001,CDM,740,RC,95940,HCPCS,,,facility,both,,,,210,157.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Gi Imag Intraluminal Esophagus-Ileum W/I&R,7509111001,CDM,750,RC,91110,HCPCS,,,facility,both,,,,2852,2139,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
LATANOPROST 0.005 % SOLN 2.5 ML BOTTLE,7531,CDM,250,RC,59762033302,NDC,,,facility,both,2.5,ML,,40.1,30.08,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % SOLN 2.5 ML BOTTLE,7531,CDM,250,RC,70069042101,NDC,,,facility,both,2.5,ML,,37.8,28.35,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % SOLN 2.5 ML BOTTLE,7531,CDM,250,RC,61314054701,NDC,,,facility,both,2.5,ML,,42.8,32.1,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Attendance At Delivery,7609946401,CDM,760,RC,99464,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ct Room Charge,7610000001,CDM,761,RC,,,,,facility,both,,,,2796,2097,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ct Cryoablation,7610000002,CDM,761,RC,,,,,facility,both,,,,21179,15884.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thoracentesis,7610000004,CDM,761,RC,,,,,facility,both,,,,1108,831,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ssu Treatment Room,7610000005,CDM,761,RC,,,,,facility,both,,,,908,681,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ssu Treatment Rm W/Anesthesia,7610000006,CDM,761,RC,,,,,facility,both,,,,1669,1251.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Treatment Room,7610000007,CDM,761,RC,,,,,facility,both,,,,1669,1251.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tis Trnfr Eyelids, Nose, Ears, And Or Lips 10.1-30Sqcm",7611406101,CDM,761,RC,14061,HCPCS,,,facility,both,,,,1795,1346.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Tis Trnfr Eyelids, Nose, Ears, And Or Lips 10.1-30Sqcm",7611406101,CDM,761,RC,14061,HCPCS,,,facility,both,,,,2064,1548,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Skin Full Graft Een & Lips,7611526001,CDM,761,RC,15260,HCPCS,,,facility,both,,,,2064,1548,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Delay Flap Eye/Nos/Ear/Lip,7611563001,CDM,761,RC,15630,HCPCS,,,facility,both,,,,2064,1548,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Revision Of Upper Eyelid,7611582301,CDM,761,RC,15823,HCPCS,,,facility,both,,,,1795,1346.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Destruct Lesion 15 Or More,7611711101,CDM,761,RC,17111,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Dstrct M Lsn Trnk/Arm/Lg 2.1-3,7611726301,CDM,761,RC,17263,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc  Destruct Skin Lesion >4.0Cm,7611726601,CDM,761,RC,17266,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Injection Single Tendon Origin/Insertion,7612055101,CDM,761,RC,20551,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Injection Single Tendon Origin/Insertion,7612055101,CDM,761,RC,20551,HCPCS,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Needle Insertion W/O Injection 1 Or 2 Muscles,7612056001,CDM,761,RC,20560,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Needle Insertion W/O Injection 3 Or More Muscles,7612056101,CDM,761,RC,20561,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cltx Proximal Humeral Fracture Without Manipulation,7612360001,CDM,761,RC,23600,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Cltx Greater Humeral Tuberosity Fx Without Manj,7612362001,CDM,761,RC,23620,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc Arm/Elbow Les Sc <3Cm,7612407501,CDM,761,RC,24075,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Ulnar Fracture,7612467001,CDM,761,RC,24670,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Transplant Hand Tendon,7612648001,CDM,761,RC,26480,HCPCS,,,facility,both,,,,3996,2997,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Cltx Artclr Fx Invg Mtcrphlngl, Iphal Jt Without Manj",7612674001,CDM,761,RC,26740,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Cltx Dstl Phlngl Fx Fngr, Thmb Without Manj Ea",7612675001,CDM,761,RC,26750,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Fusion Of Finger Jnt Add-On,7612686101,CDM,761,RC,26861,HCPCS,,,facility,both,,,,3286,2464.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Treat Hip Socket Fracture,7612722001,CDM,761,RC,27220,HCPCS,,,facility,both,,,,248,186,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Thigh Fracture,7612724601,CDM,761,RC,27246,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Kneecap Fracture,7612752001,CDM,761,RC,27520,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treat Knee Fracture,7612753001,CDM,761,RC,27530,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Treatment Of Fibula Fracture,7612778001,CDM,761,RC,27780,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Cltx Dstl Fibular Fx Lat Malls Without Manj,7612778601,CDM,761,RC,27786,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Tx Metatarsal Fx W/O Manip,7612847001,CDM,761,RC,28470,HCPCS,,,facility,both,,,,414,310.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Tx Metatarsal Fx W/O Manip,7612847001,CDM,761,RC,28470,HCPCS,,,facility,both,,,,216,162,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Unlisted Proc Abd Or Renal,7614999901,CDM,761,RC,49999,HCPCS,,,facility,both,,,,6586,4939.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Outpatient Laceration Repair,7615930001,CDM,761,RC,59300,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection(S) Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn,7616232501,CDM,761,RC,62325,HCPCS,,,facility,both,,,,2070,1552.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Of External Ear,7616910001,CDM,761,RC,69100,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Incision Of Eardrum,7616942001,CDM,761,RC,69420,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Repair Of Eardrum,7616961001,CDM,761,RC,69610,HCPCS,,,facility,both,,,,1631,1223.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Patency Capsule Swallow,7619129901,CDM,761,RC,91299,HCPCS,,,facility,both,,,,251,188.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Opscpy Extnd Rta Drawing & Scl Deprsn I&R Uni/Bi,7619220101,CDM,761,RC,92201,HCPCS,,,facility,both,,,,188,141,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Low Frequency Non-Thermal Us,7619761001,CDM,761,RC,97610,HCPCS,,,facility,both,,,,260,195,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Phototherapy Per Day,7619919901,CDM,761,RC,99199,HCPCS,,,facility,both,,,,210,157.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Visit Level Ii New Pt,7619920201,CDM,761,RC,99202,HCPCS,,,facility,both,,,,239,179.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Visit Level Ii New Pt,7619920201,CDM,761,RC,99202,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Visit Lev Iii New Pt,7619920301,CDM,761,RC,99203,HCPCS,,,facility,both,,,,270,202.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Visit Lev Iii New Pt,7619920301,CDM,761,RC,99203,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Visit Level Iv New Pt,7619920401,CDM,761,RC,99204,HCPCS,,,facility,both,,,,350,262.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Visit Level Iv New Pt,7619920401,CDM,761,RC,99204,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Visit Level V New Pt,7619920501,CDM,761,RC,99205,HCPCS,,,facility,both,,,,420,315,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Visit Level V New Pt,7619920501,CDM,761,RC,99205,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Picc Removal,7619921101,CDM,761,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Office/Outpatient Established Minimal Problem(S),7619921102,CDM,761,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Office/Outpatient Established Minimal Problem(S),7619921102,CDM,761,RC,99211,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Transtracheal Tube Assessment,7619921103,CDM,761,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Access/De-Access Port,7619921104,CDM,761,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Of Peg Tube,7619921106,CDM,761,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dressing Change,7619921107,CDM,761,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Office/Outpatient Established Sf Mdm, If Using Time, 10 Minutes Or More",7619921201,CDM,761,RC,99212,HCPCS,,,facility,both,,,,227,170.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Office/Outpatient Established Sf Mdm, If Using Time, 10 Minutes Or More",7619921201,CDM,761,RC,99212,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Office/Outpatient Established Low Mdm, If Using Time, 20 Minutes Or More",7619921301,CDM,761,RC,99213,HCPCS,,,facility,both,,,,263,197.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Office/Outpatient Established Low Mdm, If Using Time, 20 Minutes Or More",7619921301,CDM,761,RC,99213,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Office/Outpatient Established Mod , If Using Time, 30 Minutes Or More",7619921401,CDM,761,RC,99214,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"Hc Office/Outpatient Established Mod , If Using Time, 30 Minutes Or More",7619921401,CDM,761,RC,99214,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Office/Outpatient Established High Mdm, If Using Time, 40 Minutes Or More",7619921501,CDM,920,RC,99215,HCPCS,,,facility,both,,,,400,300,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Office/Outpatient Established High Mdm, If Using Time, 40 Minutes Or More",7619921501,CDM,920,RC,99215,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Attendance At Delivery,7619946401,CDM,761,RC,99464,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Advncd Care Plan 30 Min,7619949701,CDM,761,RC,99497,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Hospital Observation Per Hour,762G037800,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Observation Carve Out- Radiology,762G037802,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Observation Carve Out- Cardiology,762G037803,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Observation Carve Out-  Respiratory,762G037804,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Observation Carve Out- Gastrointestinal,762G037805,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
DIPHENHYDRAMINE 2-0.1 % CREA 28 G TUBE,764,CDM,250,RC,MHS1GM,HCPCS,45802035803,NDC,facility,both,1,GM,,1.44,1.08,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 2-0.1 % CREA 28.4 G TUBE,764,CDM,250,RC,MHS1GM,HCPCS,49348085472,NDC,facility,both,1,GM,,1.41,1.05,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Pelvic/Breast Exam Tc,770G010101,CDM,770,RC,G0101,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Admn Rsv Monoc Antb Seasonal Dos Im Cnsl Phy/Qhp, Hd",7719638001,CDM,771,RC,96380,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Admn Rsv Monoc Antb Seasonal Dos Im Cnsl Phy/Qhp, Hd",7719638001,CDM,771,RC,96380,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Admn Rsv Monoclonal Antb Seasonal Dose Im Njx,7719638101,CDM,771,RC,96381,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Admn Rsv Monoclonal Antb Seasonal Dose Im Njx,7719638101,CDM,771,RC,96381,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Influenza Vaccine Admin,771G000801,CDM,771,RC,G0008,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Influenza Vaccine Admin,771G000801,CDM,771,RC,G0008,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Pneumococcal Vaccine Admin,771G000901,CDM,771,RC,G0009,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pneumococcal Vaccine Admin,771G000901,CDM,771,RC,G0009,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Hepatitis B Vaccine Admin,771G001001,CDM,771,RC,G0010,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hepatitis B Vaccine Admin,771G001001,CDM,771,RC,G0010,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Intravenous Infusion, Casirivimab And Imdevimab, Includes Inf And Post Admin Monitoring",771M024301,CDM,771,RC,M0243,HCPCS,,,facility,both,,,,996,747,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
ERYTHROMYCIN 5 MG/GM OINT,7807,CDM,250,RC,MHS1GM,HCPCS,574402450,NDC,facility,both,1,GM,,37.8,28.35,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/GM OINT 1 G TUBE,7807,CDM,250,RC,MHS1GM,HCPCS,574402450,NDC,facility,both,1,GM,,37.8,28.35,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/GM OINT 1 G TUBE,7807,CDM,250,RC,MHS1GM,HCPCS,24208091019,NDC,facility,both,1,GM,,37.1,27.82,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/GM OINT 3.5 G TUBE,7807,CDM,250,RC,MHS1GM,HCPCS,24208091055,NDC,facility,both,1,GM,,12.55,9.41,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/GM OINT 3.5 G TUBE,7807,CDM,250,RC,MHS1GM,HCPCS,574402435,NDC,facility,both,1,GM,,12.61,9.46,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN BASE 250 MG TABS,7809,CDM,250,RC,52536010303,NDC,,,facility,both,4,UN,,17.45,13.09,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Tel Lactation Consult 15Min,7809940101,CDM,780,RC,99401,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tel Lactation Consult 30Min,7809940201,CDM,780,RC,99402,HCPCS,,,facility,both,,,,130,97.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tel Lactation Consult 45Min,7809940301,CDM,780,RC,99403,HCPCS,,,facility,both,,,,172,129,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Tel Lactation Consult 60Min,7809940401,CDM,780,RC,99404,HCPCS,,,facility,both,,,,215,161.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
ERYTHROMYCIN LACTOBIONATE SOLR 1 EACH VIAL,7826,CDM,636,RC,J1364,HCPCS,409648201,NDC,facility,both,500,ME,,153.4,115.05,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 5 MG/ML OIL,7884,CDM,636,RC,J1000,HCPCS,9027101,NDC,facility,both,5,ME,,102.35,76.76,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 G SOLR,789,CDM,636,RC,J0692,HCPCS,60505614600,NDC,facility,both,500,ME,,21.32,15.99,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 G SOLR 1 EACH VIAL,789,CDM,636,RC,J0692,HCPCS,60505614600,NDC,facility,both,500,ME,,21.32,15.99,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME SOLR,789,CDM,636,RC,J0692,HCPCS,60505614600,NDC,facility,both,500,ME,,20.96,15.72,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME SOLR 1 EACH VIAL,789,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,both,500,ME,,28.1,21.08,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME SOLR 1 EACH VIAL,789,CDM,636,RC,J0692,HCPCS,60505614600,NDC,facility,both,500,ME,,20.98,15.74,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROMETHOLONE 0.1 % SUSP 10 ML BOTTLE,79,CDM,250,RC,MHS1ML,HCPCS,60758088010,NDC,facility,both,1,ML,,23.62,17.72,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GM SOLR 1 EACH VIAL,791,CDM,636,RC,J0692,HCPCS,60505614700,NDC,facility,both,500,ME,,14.52,10.89,,,,,,,,,,Gross Charge Type: Pharmacy
ESTROGENS CONJUGATED 1.25 MG TABS,7910,CDM,250,RC,46110481,NDC,,,facility,both,1,UN,,20,15,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL CHLORIDE AERO 116 ML CAN,7939,CDM,250,RC,J3490,HCPCS,386000103,NDC,facility,both,1,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL CHLORIDE AERO 116 ML CAN,7939,CDM,250,RC,MHS1ML,HCPCS,386000103,NDC,facility,both,1,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL CHLORIDE AERO 116 ML CAN,7939,CDM,250,RC,FAMRXNC,HCPCS,386000103,NDC,facility,both,1,ML,,0.49,0.37,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL CHLORIDE AERO 116 ML GLASS CONT,7939,CDM,250,RC,FAMRXNC,HCPCS,386000103,NDC,facility,both,1,ML,,0.64,0.48,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Hemodialysis One Eval(Inpatient),8019093501,CDM,801,RC,90935,HCPCS,,,facility,both,,,,1910,1432.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hemodialysis Repeated Eval,8019093701,CDM,801,RC,90937,HCPCS,,,facility,both,,,,2250,1687.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dialysis Other/Than Hemo One Eval,8029094501,CDM,802,RC,90945,HCPCS,,,facility,both,,,,1103,827.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dialysis Other/Than Hemo Repeated Eval,8029094701,CDM,802,RC,90947,HCPCS,,,facility,both,,,,1213,909.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
DONEPEZIL 5 MG TABS,8179,CDM,250,RC,60687029201,NDC,,,facility,both,2,UN,,3.65,2.74,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 5 MG TABS,8179,CDM,250,RC,904647761,NDC,,,facility,both,4.5,UN,,1.78,1.34,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 5 MG TABS,8179,CDM,250,RC,904647761,NDC,,,facility,both,0.5,UN,,6.4,4.8,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 5 MG TABS,8179,CDM,250,RC,60687029201,NDC,,,facility,both,1,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 5 MG TABS,8179,CDM,250,RC,904647761,NDC,,,facility,both,4,UN,,2.19,1.64,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 5 MG TABS,8179,CDM,250,RC,904647761,NDC,,,facility,both,3,UN,,2.8,2.1,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 5 MG TABS,8179,CDM,250,RC,904647761,NDC,,,facility,both,2,UN,,3.8,2.85,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 5 MG TABS,8179,CDM,250,RC,904647761,NDC,,,facility,both,1,UN,,6.79,5.09,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-APAP 25-500 MG TABS,8317,CDM,250,RC,57896032405,NDC,,,facility,both,2,UN,,3.2,2.4,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-APAP 25-500 MG TABS,8317,CDM,250,RC,57896032405,NDC,,,facility,both,1,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS GLUCONATE 324 (38 FE) MG TABS,8333,CDM,250,RC,574050811,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS GLUCONATE 324 (38 FE) MG TABS,8333,CDM,250,RC,574050801,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS GLUCONATE 324 (38 FE) MG TABS,8333,CDM,250,RC,574050811,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS GLUCONATE 324 (38 FE) MG TABS,8333,CDM,250,RC,574050811,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
FISH OIL 1000 MG CAPS,8453,CDM,250,RC,77333030810,NDC,,,facility,both,2,UN,,4.25,3.19,,,,,,,,,,Gross Charge Type: Pharmacy
FISH OIL 1000 MG CAPS,8453,CDM,250,RC,77333030810,NDC,,,facility,both,1,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
FISH OIL 1000 MG CAPS,8453,CDM,250,RC,48433011001,NDC,,,facility,both,1,UN,,7.35,5.51,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE MONOBASIC/SODIUM PHOSPHATE DIBASIC 7-19 GM/118ML ENEM 133 ML BOTTLE,8480,CDM,250,RC,MHS1ML,HCPCS,132020140,NDC,facility,both,1,ML,,0.22,0.16,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ENEM 133 ML BOTTLE,8485,CDM,250,RC,132030140,NDC,,,facility,both,100.0027,ML,,22.95,17.21,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ENEM 133 ML BOTTLE,8485,CDM,250,RC,132030140,NDC,,,facility,both,133,ML,,23.85,17.89,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML SOLN,8573,CDM,250,RC,MHS1ML,HCPCS,25021031002,NDC,facility,both,1,ML,,193.9,145.42,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,8573,CDM,250,RC,MHS1ML,HCPCS,25021031002,NDC,facility,both,1,ML,,196.04,147.03,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL,8573,CDM,250,RC,MHS1ML,HCPCS,70069026101,NDC,facility,both,1,ML,,50.38,37.78,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOCINONIDE 0.05 % OINT 15 G TUBE,8609,CDM,250,RC,51672126401,NDC,,,facility,both,15,GR,,64.75,48.56,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 25 MG TABS,8617,CDM,250,RC,68084034201,NDC,,,facility,both,1,UN,,7.52,5.64,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 25 MG TABS,8617,CDM,250,RC,68084034201,NDC,,,facility,both,2,UN,,4.34,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 25 MG TABS,8617,CDM,250,RC,68084034201,NDC,,,facility,both,3,UN,,3.08,2.31,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 25 MG TABS,8617,CDM,250,RC,68084034201,NDC,,,facility,both,4,UN,,2.45,1.84,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG TABS,8626,CDM,250,RC,68084034401,NDC,,,facility,both,3,UN,,3.4,2.55,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG TABS,8626,CDM,250,RC,68084034401,NDC,,,facility,both,1.5,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG TABS,8626,CDM,250,RC,68084034401,NDC,,,facility,both,1,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG TABS,8626,CDM,250,RC,68084034401,NDC,,,facility,both,4,UN,,2.76,2.07,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG TABS,8626,CDM,250,RC,68084034401,NDC,,,facility,both,2,UN,,4.68,3.51,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,51079020520,NDC,,,facility,both,1,UN,,7.65,5.74,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,60687067701,NDC,,,facility,both,0.5,UN,,7.3,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,55111072901,NDC,,,facility,both,1,UN,,6.7,5.02,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,51079020520,NDC,,,facility,both,2,UN,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,904704161,NDC,,,facility,both,3,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,55111072901,NDC,,,facility,both,3,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,904704161,NDC,,,facility,both,2,UN,,4.55,3.41,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,904704161,NDC,,,facility,both,1,UN,,8.1,6.08,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,60687067701,NDC,,,facility,both,3,UN,,3.45,2.59,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,55111072901,NDC,,,facility,both,1.5,UN,,3.52,2.64,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,904704161,NDC,,,facility,both,1.5,UN,,4.35,3.26,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,51079020520,NDC,,,facility,both,0.5,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,55111072901,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,55111072901,NDC,,,facility,both,2,UN,,3.3,2.48,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,16714057602,NDC,,,facility,both,2,UN,,3.62,2.72,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,60687067701,NDC,,,facility,both,2,UN,,4.72,3.54,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,60687067701,NDC,,,facility,both,1,UN,,8.45,6.34,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,51079020520,NDC,,,facility,both,4,UN,,2.6,1.95,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,51079020520,NDC,,,facility,both,3,UN,,3.23,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,60687067701,NDC,,,facility,both,1.5,UN,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,16714057602,NDC,,,facility,both,1.5,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,16714057602,NDC,,,facility,both,1,UN,,6.5,4.87,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,904704161,NDC,,,facility,both,0.5,UN,,7.05,5.29,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,16714057602,NDC,,,facility,both,0.5,UN,,6.35,4.76,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,51079020520,NDC,,,facility,both,1.5,UN,,4.32,3.24,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG TABS,864,CDM,250,RC,16714057602,NDC,,,facility,both,3,UN,,2.62,1.96,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG TABS,865,CDM,250,RC,51079020620,NDC,,,facility,both,0.5,UN,,8,6,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG TABS,865,CDM,250,RC,51079020620,NDC,,,facility,both,1.5,UN,,4.88,3.66,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG TABS,865,CDM,250,RC,51079020620,NDC,,,facility,both,1,UN,,9.05,6.79,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG TABS,865,CDM,250,RC,51079020620,NDC,,,facility,both,2,UN,,5.2,3.9,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML SOLN,8653,CDM,636,RC,J2679,HCPCS,67457035959,NDC,facility,both,1.25,ME,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 5 MG/ML SOLN 10 ML VIAL,8707,CDM,250,RC,MHS1ML,HCPCS,63323018410,NDC,facility,both,1,ML,,27.66,20.75,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 5 MG/ML SOLN 10 ML VIAL,8707,CDM,250,RC,MHS1ML,HCPCS,39822110001,NDC,facility,both,1,ML,,28,21,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG TABS,8709,CDM,250,RC,60687068101,NDC,,,facility,both,2,UN,,4.1,3.07,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG TABS,8709,CDM,250,RC,60687068101,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG TABS,8709,CDM,250,RC,60687068101,NDC,,,facility,both,3,UN,,2.92,2.19,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG TABS,8709,CDM,250,RC,60687068101,NDC,,,facility,both,5,UN,,1.9,1.43,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG TABS,8709,CDM,250,RC,904722461,NDC,,,facility,both,1,UN,,6.93,5.2,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG TABS,8709,CDM,250,RC,53746036101,NDC,,,facility,both,1,UN,,6.3,4.72,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG TABS,8709,CDM,250,RC,60687068101,NDC,,,facility,both,4,UN,,2.29,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG TABS,8710,CDM,250,RC,50268034611,NDC,,,facility,both,1,UN,,7.1,5.32,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG TABS,8710,CDM,250,RC,80681009900,NDC,,,facility,both,2.5,UN,,2.08,1.56,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG TABS,8710,CDM,250,RC,80681009900,NDC,,,facility,both,2,UN,,3.1,2.32,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG TABS,8710,CDM,250,RC,50268034611,NDC,,,facility,both,2.5,UN,,2.85,2.14,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG TABS,8710,CDM,250,RC,50268034611,NDC,,,facility,both,4,UN,,2.29,1.72,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG TABS,8710,CDM,250,RC,50268034611,NDC,,,facility,both,2,UN,,4.08,3.06,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG TABS,8710,CDM,250,RC,80681009900,NDC,,,facility,both,1,UN,,6.1,4.58,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML IJ SOLN,8861,CDM,409610210,NDC,,,,,facility,both,20,ML,,6.47,4.85,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8861,CDM,636,RC,J1940,HCPCS,409610225,NDC,facility,both,20,ME,,23.03,17.27,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8861,CDM,636,RC,J1940,HCPCS,409610210,NDC,facility,both,20,ME,,4.5,3.38,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8861,CDM,636,RC,J1940,HCPCS,63323028002,NDC,facility,both,20,ME,,30.5,22.87,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8861,CDM,636,RC,J1940,HCPCS,16729050143,NDC,facility,both,20,ME,,22.88,17.16,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8861,CDM,636,RC,J1940,HCPCS,36000028325,NDC,facility,both,20,ME,,15.93,11.95,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8861,CDM,636,RC,J1940,HCPCS,409610204,NDC,facility,both,20,ME,,13.94,10.45,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8861,CDM,636,RC,J1940,HCPCS,55150032325,NDC,facility,both,20,ME,,14.9,11.18,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8861,CDM,636,RC,J1940,HCPCS,72572019001,NDC,facility,both,20,ME,,14.67,11.01,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8861,CDM,636,RC,J1940,HCPCS,409610202,NDC,facility,both,20,ME,,21.29,15.97,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN 10 ML VIAL,8861,CDM,636,RC,J1940,HCPCS,409610210,NDC,facility,both,20,ME,,4.45,3.33,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN 2 ML VIAL,8861,CDM,636,RC,J1940,HCPCS,409610202,NDC,facility,both,20,ME,,8.14,6.1,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN 4 ML VIAL,8861,CDM,636,RC,J1940,HCPCS,409610204,NDC,facility,both,20,ME,,6.55,4.91,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN 4 ML VIAL,8861,CDM,636,RC,J1940,HCPCS,72572019001,NDC,facility,both,20,ME,,7.31,5.48,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML SOLN,8862,CDM,250,RC,MHS2ML,HCPCS,54329446,NDC,facility,both,2,ML,,3.65,2.73,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,904717761,NDC,,,facility,both,2,UN,,3.48,2.61,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,51079007220,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,51079007220,NDC,,,facility,both,2,UN,,3.42,2.57,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,51079007220,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,54829725,NDC,,,facility,both,2,UN,,3.22,2.42,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,54829725,NDC,,,facility,both,4,UN,,1.71,1.28,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,54829725,NDC,,,facility,both,1.5,UN,,3.18,2.38,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,54829725,NDC,,,facility,both,1,UN,,6.25,4.68,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,54829725,NDC,,,facility,both,0.5,UN,,6.15,4.61,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,54829725,NDC,,,facility,both,3,UN,,2.22,1.66,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,904717761,NDC,,,facility,both,1,UN,,6.5,4.88,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG TABS,8864,CDM,250,RC,904717761,NDC,,,facility,both,0.5,UN,,6.25,4.69,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG TABS,8865,CDM,250,RC,54829925,NDC,,,facility,both,2,UN,,3.28,2.46,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG TABS,8865,CDM,250,RC,54829925,NDC,,,facility,both,0.5,UN,,6.2,4.65,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG TABS,8865,CDM,250,RC,54829925,NDC,,,facility,both,1.5,UN,,3.25,2.44,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG TABS,8865,CDM,250,RC,54829925,NDC,,,facility,both,1,UN,,6.19,4.64,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG TABS,9044,CDM,250,RC,50268035015,NDC,,,facility,both,1,UN,,7.7,5.78,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG TABS,9044,CDM,250,RC,50268035015,NDC,,,facility,both,0.5,UN,,6.85,5.14,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG TABS,9044,CDM,250,RC,60687022401,NDC,,,facility,both,1,UN,,7.4,5.55,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Intensive Outpatient Psychia,905S948001,CDM,905,RC,S9480,HCPCS,,,facility,both,,,,307,230.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Intensive Outpatient Psychia,905S948001,CDM,905,RC,S9480,HCPCS,,,facility,both,,,,307,230.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Alcohol And/Or Drug Services,906H001501,CDM,906,RC,H0015,HCPCS,,,facility,both,,,,307,230.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Alcohol And/Or Drug Services,906H001501,CDM,906,RC,H0015,HCPCS,,,facility,both,,,,307,230.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
ALPRAZOLAM 0.25 MG TABS,913,CDM,250,RC,781106101,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG TABS,913,CDM,250,RC,59762371901,NDC,,,facility,both,4,UN,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG TABS,913,CDM,250,RC,59762371901,NDC,,,facility,both,1,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG TABS,913,CDM,250,RC,781106101,NDC,,,facility,both,4,UN,,1.36,1.02,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG TABS,913,CDM,250,RC,781106101,NDC,,,facility,both,1,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG TABS,913,CDM,250,RC,781106101,NDC,,,facility,both,2,UN,,2.68,2.01,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG TABS,913,CDM,250,RC,59762371901,NDC,,,facility,both,2,UN,,2.68,2.01,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG TABS,914,CDM,250,RC,228202910,NDC,,,facility,both,1,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG TABS,914,CDM,250,RC,59762372001,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG TABS,914,CDM,250,RC,59762372001,NDC,,,facility,both,4,UN,,1.38,1.03,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG TABS,914,CDM,250,RC,59762372001,NDC,,,facility,both,1,UN,,5.3,3.98,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG TABS,914,CDM,250,RC,228202910,NDC,,,facility,both,2,UN,,2.7,2.02,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG TABS,914,CDM,250,RC,781107701,NDC,,,facility,both,2,UN,,2.68,2.01,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG TABS,914,CDM,250,RC,228202910,NDC,,,facility,both,4,UN,,1.4,1.05,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG TABS,914,CDM,250,RC,228202910,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG TABS,914,CDM,250,RC,59762372001,NDC,,,facility,both,2,UN,,2.68,2.01,,,,,,,,,,Gross Charge Type: Pharmacy
Hc O/P Case Mgmt Pr Unit Guardian,9140000001,CDM,914,RC,,,,,facility,both,,,,15,11.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
ALPRAZOLAM 1 MG TABS,915,CDM,250,RC,59762372101,NDC,,,facility,both,3,UN,,1.8,1.35,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 1 MG TABS,915,CDM,250,RC,59762372101,NDC,,,facility,both,1,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 1 MG TABS,915,CDM,250,RC,59762372101,NDC,,,facility,both,2,UN,,2.68,2.01,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 1 MG TABS,915,CDM,250,RC,59762372101,NDC,,,facility,both,0.5,UN,,5.25,3.94,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 0.1 % CREA 15 G TUBE,9157,CDM,250,RC,45802005635,NDC,,,facility,both,15,GR,,98.95,74.21,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 0.1 % OINT 15 G TUBE,9158,CDM,250,RC,MHS1GM,HCPCS,45802004635,NDC,facility,both,1,GM,,6.64,4.98,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Group Psychotherapy,9159085303,CDM,915,RC,90853,HCPCS,,,facility,both,,,,249,186.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
GENTAMICIN 40 MG/ML SOLN,9161,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,both,80,ME,,35.12,26.34,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML SOLN 2 ML VIAL,9161,CDM,636,RC,J1580,HCPCS,409120703,NDC,facility,both,80,ME,,13.88,10.41,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML SOLN 2 ML VIAL,9161,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,both,80,ME,,17.85,13.39,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML SOLN 20 ML VIAL,9161,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,both,80,ME,,14.96,11.22,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 0.3 % SOLN 5 ML BOTTLE,9163,CDM,250,RC,MHS1ML,HCPCS,24208058060,NDC,facility,both,1,ML,,16.62,12.46,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Quan Mr Alys Tiss Composition W/Mri 1Orgn - Add On,9200649T01,CDM,920,RC,0649T,HCPCS,,,facility,both,,,,690,517.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Special Eye Eval, Goniscopy",9209202001,CDM,920,RC,92020,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Ob Check 1St Hr,9209921101,CDM,920,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Home Sleep Test W Type Iii Portable Monitor,920G039901,CDM,920,RC,G0399,HCPCS,,,facility,both,,,,276,207,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Screening Pap Smear Tc,923Q009101,CDM,923,RC,Q0091,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Proc-Feeds-Tube (Ng,Gj,J-Tube,G-Tube)",9310210,CDM,999,RC,,,,,facility,both,,,,215,161.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mr-Knee Prod Only,9312075,CDM,999,RC,73721,HCPCS,,,facility,both,,,,1762,1321.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Knee Prod Only,9312293,CDM,999,RC,73700,HCPCS,,,facility,both,,,,1246,934.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Lspine W/O Contrast Reformat,9312307,CDM,999,RC,72131,HCPCS,,,facility,both,,,,1175,881.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Ct Cspine W/O Contrast Reformat,9312313,CDM,999,RC,72125,HCPCS,,,facility,both,,,,1150,862.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Ct Ankle Prod Only,9312341,CDM,999,RC,73700,HCPCS,,,facility,both,,,,1246,934.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Lower Extrem W/O Contrast Reformat,9312370,CDM,999,RC,73700,HCPCS,,,facility,both,,,,1246,934.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Shoulder,9312376,CDM,999,RC,73200,HCPCS,,,facility,both,,,,1488,1116,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ultrasonic Guidance Needle Placement:Biopsy,Aspiration,Injection,Localization Device Imaging Super",9312384,CDM,999,RC,76942,HCPCS,,,facility,both,,,,650,487.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
GLYBURIDE 5 MG TABS,9379,CDM,250,RC,93834401,NDC,,,facility,both,1,UN,,7,5.25,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML SOLN,9401,CDM,250,RC,43547054301,NDC,,,facility,both,0.1,ME,,25.39,19.04,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML SOLN,9401,CDM,250,RC,143968225,NDC,,,facility,both,0.1,ME,,26.65,19.98,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML SOLN,9401,CDM,250,RC,16729047163,NDC,,,facility,both,0.1,ME,,209.95,157.46,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML SOLN,9401,CDM,250,RC,J1596,HCPCS,66794020242,NDC,facility,both,0.1,ME,,14.51,10.89,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML SOLN,9401,CDM,636,RC,J1596,HCPCS,66794020242,NDC,facility,both,0.1,ME,,17.4,13.05,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML SOLN,9401,CDM,250,RC,66794020242,NDC,,,facility,both,0.1,ME,,31.19,23.39,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML SOLN,9401,CDM,250,RC,63323057803,NDC,,,facility,both,0.1,ME,,38.89,29.17,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML SOLN,9401,CDM,636,RC,J1596,HCPCS,63323057803,NDC,facility,both,0.1,ME,,19.07,14.3,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML SOLN,9401,CDM,636,RC,J1596,HCPCS,143968225,NDC,facility,both,0.1,ME,,12.01,9.01,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Trim Dystrophic Nails,940G012701,CDM,940,RC,G0127,HCPCS,,,facility,both,,,,169,126.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Trim Dystrophic Nails,940G012701,CDM,940,RC,G0127,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Ip Lactation Consult Initial 15Min,9420000001,CDM,942,RC,,,,,facility,both,,,,152,114,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ip Lactation Consult Addl 15Min,9420000002,CDM,942,RC,,,,,facility,both,,,,69,51.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
AZELASTINE 0.1 % SOLN,9429,CDM,250,RC,51991081403,NDC,,,facility,both,0.15,ML,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
AZELASTINE 0.1 % SOLN,9429,CDM,250,RC,51991081403,NDC,,,facility,both,0.3,ML,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,9429,CDM,250,RC,60505083305,NDC,,,facility,both,0.3,ML,,0.55,0.41,,,,,,,,,,Gross Charge Type: Pharmacy
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,9429,CDM,250,RC,60505083305,NDC,,,facility,both,30,ML,,37.4,28.05,,,,,,,,,,Gross Charge Type: Pharmacy
AZELASTINE 0.1 % SOLN 30 ML BOTTLE,9429,CDM,250,RC,60505083305,NDC,,,facility,both,0.15,ML,,0.3,0.22,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Medical Nutrition Assessmnt Indiv Each 15 Min,9429780201,CDM,942,RC,97802,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Medical Nutrition Re-Assmt Indiv Ea 15 Min,9429780301,CDM,942,RC,97803,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hb Education And Training For Patient Self-Mgmt,9429896001,CDM,942,RC,98960,HCPCS,,,facility,both,,,,97,72.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Weight Chk / Bili Monitor,9429921101,CDM,942,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lactation Consult 15Min,9429940101,CDM,942,RC,99401,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lactation Consult 30Min,9429940201,CDM,942,RC,99402,HCPCS,,,facility,both,,,,130,97.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lactation Consult 45Min,9429940301,CDM,942,RC,99403,HCPCS,,,facility,both,,,,172,129,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Lactation Consult 60Min,9429940401,CDM,942,RC,99404,HCPCS,,,facility,both,,,,227,170.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Outpatient Pulmonary Rehabilitation Without Continous Oximetry Monitoring (Per Session),9489462501,CDM,948,RC,94625,HCPCS,,,facility,both,,,,328,246,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ane-Nerve Block 15 Min,9510013,CDM,370,RC,,,,,facility,both,,,,753,564.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Bc-C-Section,9510021,CDM,722,RC,59514,HCPCS,,,facility,both,,,,1755,1316.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Bc-Epidural Block,9510030,CDM,370,RC,,,,,facility,both,,,,950,712.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Insertion Of Non-Indwelling Bladder Catheter,9510032,CDM,761,RC,51701,HCPCS,,,facility,both,,,,213,159.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Insertion Of Non-Indwelling Bladder Catheter,9510032,CDM,761,RC,51701,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Insertion Of Temporary Indwelling Bladder Catheter; Simple,9510033,CDM,761,RC,51702,HCPCS,,,facility,both,,,,174,130.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Insertion Of Temporary Indwelling Bladder Catheter; Simple,9510033,CDM,761,RC,51702,HCPCS,,,facility,both,,,,306,229.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Insertion Of Temporary Indwelling Bladder Catheter; Simple,9510033,CDM,761,RC,51702,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Bc-Non Stress Test,9510039,CDM,920,RC,59025,HCPCS,,,facility,both,,,,630,472.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Bc-Non Stress Test,9510039,CDM,920,RC,59025,HCPCS,,,facility,both,,,,179,134.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Bc-Version, External",9510048,CDM,720,RC,59412,HCPCS,,,facility,both,,,,3920,2940,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angiography Extremity Unilateral Rs&I,9510065,CDM,323,RC,75710,HCPCS,,,facility,both,,,,4500,3375,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Upgrade Implanted Pacemaker From Single Chamber To Dual Chamber,9510091,CDM,361,RC,33214,HCPCS,,,facility,both,,,,26610,19957.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Insert 2 Transvenous Electrodes,Permanent Pacemaker Or Implantable Defibrillator",9510102,CDM,361,RC,33217,HCPCS,,,facility,both,,,,32106,24079.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Removal Single Or Dual Chamber Implantable Defibrillator Electrode By Transvenous Extraction,9510106,CDM,361,RC,33244,HCPCS,,,facility,both,,,,4312,3234,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Removal Implantable Defibrillator Pulse Generator Only,9510107,CDM,361,RC,33241,HCPCS,,,facility,both,,,,5729,4296.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Insert Implantable Defibrillator Pulse Generator Only W/Existing Single Lead,9510119,CDM,361,RC,33240,HCPCS,,,facility,both,,,,30344,22758,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Insert Pacemaker Pulse Generator Only,W/Existing Dual Leads",9510124,CDM,361,RC,33213,HCPCS,,,facility,both,,,,16201,12150.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Insert Single Transvenous Electrode,Permanent Pacemaker Or Implantable Defibrillator",9510126,CDM,361,RC,33216,HCPCS,,,facility,both,,,,10805,8103.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Insert Or Replacement Permanent Implantable Defibrillator System,W/Transvenous Lead(S) Single Or D",9510127,CDM,481,RC,33249,HCPCS,,,facility,both,,,,49153,36864.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Insert Or Replacement Temporary Transvenous Single Chamber Cardiac Electrode Or Pacemaker Catheter,9510128,CDM,361,RC,33210,HCPCS,,,facility,both,,,,10065,7548.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insertion Intra-Aortic Balloon Assist Dev Perq,9510130,CDM,361,RC,33967,HCPCS,,,facility,both,,,,5808,4356,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mod Sed Svc Diff Md Ea Addl 15 Min,9510148,CDM,370,RC,99157,HCPCS,,,facility,both,,,,205,153.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Insert New Or Replacement Permanent Pacemaker W/Transvenous Electrode:Ventricular,9510158,CDM,361,RC,33207,HCPCS,,,facility,both,,,,18079,13559.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Insert New Or Replacement Permanent Pacemaker W/Transvenous Electrode:Atrial And Ventricular,9510159,CDM,361,RC,33208,HCPCS,,,facility,both,,,,24956,18717,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Insert New Or Replacement Permanent Pacemaker W/Transvenous Electrode:Atrial,9510160,CDM,361,RC,33206,HCPCS,,,facility,both,,,,18539,13904.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Removal Transvenous Pacemaker Electrode;Dual Lead System,9510182,CDM,361,RC,33235,HCPCS,,,facility,both,,,,13575,10181.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Removal Permanent Pacemaker Pulse Generatory Only,9510184,CDM,361,RC,33233,HCPCS,,,facility,both,,,,9823,7367.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Removal Transvenous Pacemaker Electrode;Single Lead System,Atrial Or Ventricular",9510185,CDM,361,RC,33234,HCPCS,,,facility,both,,,,4336,3252,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Repair Single Transvenous Electrode,Permanent Pacemaker Or Implantable Defibrillator",9510187,CDM,361,RC,33218,HCPCS,,,facility,both,,,,13575,10181.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Repositioning Previously Implanted Transvenous Pacemaker Or Implantable Defibrillator Rt Atrial Or,9510189,CDM,361,RC,33215,HCPCS,,,facility,both,,,,5640,4230,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Relocation Skin Pocket For Implantable Defibrillator,9510190,CDM,361,RC,33223,HCPCS,,,facility,both,,,,3852,2889,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Relocation Skin Pocket For Pacemaker,9510191,CDM,361,RC,33222,HCPCS,,,facility,both,,,,3271,2453.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Cpel-Mult Spirometic Evaluations,9510237,CDM,460,RC,94070,HCPCS,,,facility,both,,,,999,749.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Dbe-Diabetes Eval/Ed,Indiv,Ea 30 Min--Rd",9510244,CDM,942,RC,G0108,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Echo-Doppler Echo Exam, Heart",9510248,CDM,483,RC,93320,HCPCS,,,facility,both,,,,750,562.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Echo-Doppler Echo Exam, Heart",9510248,CDM,483,RC,93320,HCPCS,,,facility,both,,,,232,174,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Echo-Doppler Follow-Up Or Lmt Study,9510249,CDM,483,RC,93321,HCPCS,,,facility,both,,,,105,78.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Echo-Doppler Follow-Up Or Lmt Study,9510249,CDM,483,RC,93321,HCPCS,,,facility,both,,,,525,393.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo-Doppler Follow-Up Or Lmt Study,9510249,CDM,483,RC,93321,HCPCS,,,facility,both,,,,525,393.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Complete Tthrc Echo Congenital Cardiac Anomaly Wo/ Contrast,9510251,CDM,483,RC,93303,HCPCS,,,facility,both,,,,2493,1869.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo Transthorc R-T 2D W/Wo M-Mode Rec F-Up/Lmtd Wo/ Contrast,9510253,CDM,483,RC,93308,HCPCS,,,facility,both,,,,1147,860.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo Transthorc R-T 2D W/Wo M-Mode Rec F-Up/Lmtd Wo/ Contrast,9510253,CDM,483,RC,93308,HCPCS,,,facility,both,,,,1147,860.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Echo Transthorc R-T 2D W/Wo M-Mode Rec F-Up/Lmtd Wo/ Contrast,9510253,CDM,483,RC,93308,HCPCS,,,facility,both,,,,642,481.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc F-Up/Limited Tthrc Echo Congenital Car Anomaly Wo/ Contrast,9510254,CDM,483,RC,93304,HCPCS,,,facility,both,,,,1109,831.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc F-Up/Limited Tthrc Echo Congenital Car Anomaly Wo/ Contrast,9510254,CDM,483,RC,93304,HCPCS,,,facility,both,,,,1109,831.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo Transesophag (Tee) Montr Cardiac Pump Functj,9510264,CDM,483,RC,93318,HCPCS,,,facility,both,,,,3153,2364.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc  Echo Transesophag R-T 2D W/Prb Img Acquisj I&R Wo/ Contrast,9510265,CDM,483,RC,93312,HCPCS,,,facility,both,,,,2900,2175,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ekg-Cardiovascular Stress Test,9510274,CDM,482,RC,93017,HCPCS,,,facility,both,,,,990,742.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ekg-Cardiovascular Stress Test,9510274,CDM,482,RC,93017,HCPCS,,,facility,both,,,,668,501,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ephys-Ablation Av Node,9510277,CDM,481,RC,93650,HCPCS,,,facility,both,,,,10887,8165.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ephys-Comp Ep W Left Atrial Recordings,9510280,CDM,480,RC,93621,HCPCS,,,facility,both,,,,8810,6607.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ephys-Comp Ep W Left Ventrical Recording,9510281,CDM,480,RC,93622,HCPCS,,,facility,both,,,,4637,3477.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ephys-Comp Study W/-Attempted Induct Arr,9510283,CDM,480,RC,93620,HCPCS,,,facility,both,,,,11025,8268.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ep Eval Defib/Program,9510287,CDM,480,RC,93642,HCPCS,,,facility,both,,,,4984,3738,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ephys-Ep Eval C-D/Test C-D Pulse Ge,9510288,CDM,480,RC,93641,HCPCS,,,facility,both,,,,4631,3473.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ep-Insert Pacing Ld Incl Rem/Rep Icd Gen,9510293,CDM,480,RC,33224,HCPCS,,,facility,both,,,,16922,12691.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ephys-Intracardiac Mapping,9510297,CDM,480,RC,93609,HCPCS,,,facility,both,,,,6062,4546.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ep-Ins L-Vent Pac Lead Pm/Icd,9510298,CDM,361,RC,33225,HCPCS,,,facility,both,,,,25808,19356,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ephys-Program Stimula & Pacing W Infusio,9510305,CDM,480,RC,93623,HCPCS,,,facility,both,,,,6487,4865.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mod Sed Svc Diff Md 5Yrs+, 15 Min",9510333,CDM,370,RC,99156,HCPCS,,,facility,both,,,,427,320.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mod Sed Svc Same Md <5Y Initial 15 Min,9510335,CDM,370,RC,99151,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mod Sed Svc Same Md <5Y Initial 15 Min,9510335,CDM,370,RC,99151,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Mod Sed Svc Same Md 5Y+ Initial 15 Min,9510336,CDM,370,RC,99152,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mod Sed Svc Same Md 5Y+ Initial 15 Min,9510336,CDM,370,RC,99152,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Mod Sed Svc Same Md Ea Addl 15 Min,9510337,CDM,370,RC,99153,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Mod Sed Svc Same Md Ea Addl 15 Min,9510337,CDM,370,RC,99153,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Iv-Bld Draw From Compl Impltd Vad,9510338,CDM,300,RC,36591,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Iv-Capillary Puncture (Blood Draw),9510340,CDM,300,RC,36416,HCPCS,,,facility,both,,,,46,34.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Iv-Capillary Puncture (Blood Draw),9510340,CDM,300,RC,36416,HCPCS,,,facility,both,,,,17,12.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
Hc Declotting By Thrombolytic Agent Of Implanted Vascular Access Device Or Catheter,9510342,CDM,761,RC,36593,HCPCS,,,facility,both,,,,691,518.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Declotting By Thrombolytic Agent Of Implanted Vascular Access Device Or Catheter,9510342,CDM,761,RC,36593,HCPCS,,,facility,both,,,,691,518.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Phlebotomy Therapeutic Separate Procedure,9510347,CDM,940,RC,99195,HCPCS,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Iv-Venipuncture,9510355,CDM,300,RC,36415,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Iv-Venipuncture,9510355,CDM,300,RC,36415,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
C Iv-Venipuncture,9510355,CDM,300,RC,36415,HCPCS,,,facility,both,,,,8,6,,,,,,,,,,Gross Charge Type: Fsc Niach 10815342_Unit Charge
C Iv-Venipuncture,9510355,CDM,300,RC,36415,HCPCS,,,facility,both,,,,45,33.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Iv-Venipuncture,9510355,CDM,300,RC,36415,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Chemical Cauterization Of Granulation Tissue (Proud Flesh, Sinus Or Fistula)",9510361,CDM,361,RC,17250,HCPCS,,,facility,both,,,,438,328.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Chemical Cauterization Of Granulation Tissue (Proud Flesh, Sinus Or Fistula)",9510361,CDM,361,RC,17250,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Immunization Administration, Each Additional",9510365,CDM,771,RC,90472,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Immunization Administration, Each Additional",9510365,CDM,771,RC,90472,HCPCS,,,facility,both,,,,24,18,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Immunization Administration, Each Additional",9510365,CDM,771,RC,90472,HCPCS,,,facility,both,,,,63,47.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Immunization Administration, 1 Vaccine",9510366,CDM,771,RC,90471,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Immunization Administration, 1 Vaccine",9510366,CDM,771,RC,90471,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Immunization Administration, 1 Vaccine",9510366,CDM,771,RC,90471,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Mbop-Venipuncture <3 Yr Other Vein,9510374,CDM,920,RC,36406,HCPCS,,,facility,both,,,,213,159.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Blood/Blood Prod Transfused,9510379,CDM,391,RC,36430,HCPCS,,,facility,both,,,,1305,978.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Chemo Admin Sc/Im;Hormonal,9510387,CDM,331,RC,96402,HCPCS,,,facility,both,,,,387,290.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Chemo Admin Sc/Im;Nonhormonal,9510388,CDM,331,RC,96401,HCPCS,,,facility,both,,,,387,290.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Implantable Pump Refill/Maintenance,9510393,CDM,761,RC,96522,HCPCS,,,facility,both,,,,928,696,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Influenza Vaccine Admin,9510394,CDM,771,RC,90471,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Mhoc-Init Chemo Inf>8Hr Port/Imp Pumpq,9510395,CDM,335,RC,96416,HCPCS,,,facility,both,,,,1429,1071.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Irrigation Implntd Venous Access Drug Delivery Syst,9510396,CDM,761,RC,96523,HCPCS,,,facility,both,,,,316,237,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Therapeutic Prophylactic/Dx Injection Subq/Im,9510403,CDM,940,RC,96372,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Therapeutic Prophylactic/Dx Injection Subq/Im,9510403,CDM,940,RC,96372,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Therapeutic Prophylactic/Dx Injection Subq/Im,9510403,CDM,940,RC,96372,HCPCS,,,facility,both,,,,150,112.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Pneumococcal Vaccine Admin,9510406,CDM,771,RC,90471,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Mhoc-Portable Pump Refill/Maintenance,9510407,CDM,761,RC,96521,HCPCS,,,facility,both,,,,928,696,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Unlisted Chemother Proc,9510410,CDM,335,RC,96549,HCPCS,,,facility,both,,,,313,234.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Neuro-Burr Hole,Impl Vent Cath/Recor Dev",9510419,CDM,361,RC,61107,HCPCS,,,facility,both,,,,1654,1240.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Outpatient Cardiac Rehab With Continuous Ecg Monitoring, Per Session",9510431,CDM,943,RC,93798,HCPCS,,,facility,both,,,,355,266.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ocr-Holter Monitoring Analysis W/Report,9510433,CDM,731,RC,93226,HCPCS,,,facility,both,,,,646,484.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ocr-Holter Monitoring Analysis W/Report,9510433,CDM,731,RC,93226,HCPCS,,,facility,both,,,,378,283.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ocr-Holter Monitoring Hookup,9510434,CDM,731,RC,93225,HCPCS,,,facility,both,,,,552,414,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ocr-Holter Monitoring Hookup,9510434,CDM,731,RC,93225,HCPCS,,,facility,both,,,,378,283.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ocr-Prev Card Visit W/O Monitoring,9510436,CDM,943,RC,93797,HCPCS,,,facility,both,,,,298,223.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Injection(S), Anesthetic Agent(S) And/Or Steroid; Femoral Nerve, Including Imaging Guidance, When",9510464,CDM,490,RC,64447,HCPCS,,,facility,both,,,,2597,1947.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Injection Procedure Sacroiliac Joint Inc Arthrography When Performed,9510477,CDM,361,RC,27096,HCPCS,,,facility,both,,,,924,693,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Therapeutic Apheresis Red Blood Cells,9510517,CDM,361,RC,36512,HCPCS,,,facility,both,,,,5408,4056,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Measurement Of Post-Voiding Residual Urine And/Or Bladder Capacity By Ultrasound, Non-Imaging",9510519,CDM,761,RC,51798,HCPCS,,,facility,both,,,,251,188.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Measurement Of Post-Voiding Residual Urine And/Or Bladder Capacity By Ultrasound, Non-Imaging",9510519,CDM,761,RC,51798,HCPCS,,,facility,both,,,,251,188.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Measurement Of Post-Voiding Residual Urine And/Or Bladder Capacity By Ultrasound, Non-Imaging",9510519,CDM,761,RC,51798,HCPCS,,,facility,both,,,,60,45,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Cardioversion Elective Arrhythmia External,9510520,CDM,480,RC,92960,HCPCS,,,facility,both,,,,2157,1617.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Hemodialysis Procedure,9510526,CDM,801,RC,90935,HCPCS,,,facility,both,,,,2558,1918.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Proc-Insertion Art Line,9510527,CDM,361,RC,,,,,facility,both,,,,725,543.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nitric Oxide Daily Charge,9510535,CDM,410,RC,94799,HCPCS,,,facility,both,,,,3504,2628,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Proc-Nitric Oxide Therapy Per Hour,9510536,CDM,410,RC,94799,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Smoking And Tobacco Use Intensive Counseling, 4-10 Minutes",9510538,CDM,942,RC,99406,HCPCS,,,facility,both,,,,66,49.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Smoking And Tobacco Use Intensive Counseling, 4-10 Minutes",9510538,CDM,942,RC,99406,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Tracheostomy, Emergency Procedure; Cricothyroid Membrane",9510541,CDM,361,RC,31605,HCPCS,,,facility,both,,,,1738,1303.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Proc-Unsched Hemodialysis Esrd Pt,9510545,CDM,820,RC,G0257,HCPCS,,,facility,both,,,,1268,951,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Sarc-Colposcopy, Cervix&Upper Vag Fac",9510547,CDM,510,RC,57452,HCPCS,,,facility,both,,,,52,39,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Colposcopy Vagina W/Cervix 57420,9510548,CDM,361,RC,57420,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Slp-Mult Sleep Latency Testing,9510564,CDM,740,RC,95805,HCPCS,,,facility,both,,,,4670,3502.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Polysomnography Greater 6 Yrs With 4 0R More Addtl Param,9510565,CDM,740,RC,95810,HCPCS,,,facility,both,,,,5412,4059,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Slp-Polysomnography W/Cpap,9510566,CDM,740,RC,95811,HCPCS,,,facility,both,,,,5412,4059,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot-Physical Performance Test Each 15 Min,9510590,CDM,430,RC,97750,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot-Wheelchair Mgmt/Propulsion Ea 15Min,9510593,CDM,430,RC,97542,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Physical Performance Test 15 Min,9510598,CDM,420,RC,97750,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Wheelchair Mgm/Propulsion Ea 15Min,9510600,CDM,420,RC,97542,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rdtx-Continuing Medical Physics Consult,9510601,CDM,333,RC,77336,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St-Eval Non Speech Gen Device,9510603,CDM,444,RC,92605,HCPCS,,,facility,both,,,,380,285,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St-Eval Speech Gen Device 1St Hour,9510604,CDM,444,RC,92607,HCPCS,,,facility,both,,,,407,305.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St-Eval Speech Gen Device Ea Addtl 30Mn,9510605,CDM,444,RC,92608,HCPCS,,,facility,both,,,,98,73.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St-Eval Swallowing,9510607,CDM,444,RC,92610,HCPCS,,,facility,both,,,,393,294.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Adult Vent Mgmt First Day,9510625,CDM,412,RC,94002,HCPCS,,,facility,both,,,,2063,1547.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Helium/Oxygen Therapy Per Day,9510628,CDM,410,RC,,,,,facility,both,,,,1345,1008.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Ped/Neo Vent Mgmt First Day-Conv,9510636,CDM,412,RC,94002,HCPCS,,,facility,both,,,,2063,1547.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Ped/Neo Vent Mgmt First Day-High,9510637,CDM,412,RC,94002,HCPCS,,,facility,both,,,,2063,1547.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Ped/Neo Vent Mgmt Subsequent Day-Conv,9510638,CDM,412,RC,94003,HCPCS,,,facility,both,,,,1920,1440,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Ped/Neo Vent Mgmt Subsequent Day-High,9510639,CDM,412,RC,94003,HCPCS,,,facility,both,,,,1920,1440,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot-Aquatic Therapy 15Min,9510647,CDM,430,RC,97113,HCPCS,,,facility,both,,,,145,108.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot-Electrical Stimulation-Manual Ea 15Mi,9510648,CDM,430,RC,97032,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot-Neuromuscular Reeducation,9510650,CDM,430,RC,97112,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot-Orthotic Mgmt/Train Ea 15 Min,9510651,CDM,430,RC,97760,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot-Paraffin Bath,9510653,CDM,430,RC,97018,HCPCS,,,facility,both,,,,34,25.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot-Therapeutic Exercise Each 15Min,9510656,CDM,430,RC,97110,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot-Ultrasound Each 15 Min,9510657,CDM,430,RC,97035,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rdtx-Basic Radiation Dosimetry Calcs,9510665,CDM,333,RC,77300,HCPCS,,,facility,both,,,,234,175.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rdtx-Rx Dev/Des/Const Cmplx,9510666,CDM,333,RC,77334,HCPCS,,,facility,both,,,,449,336.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rdtx-Rx Dev/Des/Const Intermediate,9510667,CDM,333,RC,77333,HCPCS,,,facility,both,,,,336,252,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rdtx-Simulation-Aided Field Setting 3-D,9510701,CDM,333,RC,77295,HCPCS,,,facility,both,,,,1715,1286.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rdtx-Simulation-Aided Field Setting-Comp,9510702,CDM,333,RC,77290,HCPCS,,,facility,both,,,,1715,1286.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rdtx-Simulation-Aided Field Setting-Simp,9510704,CDM,333,RC,77280,HCPCS,,,facility,both,,,,887,665.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rdtx-Special Dosimetry (Tld/Microdosim),9510705,CDM,333,RC,77331,HCPCS,,,facility,both,,,,186,139.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rdtx-Special Trtmnt Procedure,9510706,CDM,333,RC,77470,HCPCS,,,facility,both,,,,385,288.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rdtx-Therapeutic Radiology Port Film(S),9510713,CDM,333,RC,77417,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Stereotactic Body Radiation Delivery,9510715,CDM,333,RC,77373,HCPCS,,,facility,both,,,,3074,2305.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Adult Vent Mgmt Subsequent Day,9510723,CDM,412,RC,94003,HCPCS,,,facility,both,,,,1920,1440,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Aerosol/Humidity Therapy/Day,9510724,CDM,410,RC,94640,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Arterial Blood Draw,9510725,CDM,920,RC,36600,HCPCS,,,facility,both,,,,139,104.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Bronchoscopy Procedure,9510728,CDM,361,RC,,,,,facility,both,,,,1743,1307.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Chest Physiotherapy Initial Treatment,9510730,CDM,410,RC,94667,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Chest Physiotherapy Subsequent Trmt,9510731,CDM,410,RC,94668,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Bipap Vent Mgmt First Day,9510732,CDM,412,RC,94660,HCPCS,,,facility,both,,,,726,544.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Continuous Bipap Subsequent Day,9510733,CDM,412,RC,94660,HCPCS,,,facility,both,,,,726,544.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Cpap Initiation/Mgmt Per Day,9510735,CDM,410,RC,94660,HCPCS,,,facility,both,,,,726,544.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Demo/Eval Ippb/Ez-Pap (One/Day),9510738,CDM,410,RC,94664,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Demo/Eval M-D-Inhaler  (One/Day),9510739,CDM,410,RC,94664,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Demo/Eval Svn (One/Day),9510742,CDM,410,RC,94664,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Ippb/Ez-Pap Treatment,9510749,CDM,410,RC,94640,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Management Home Bipap First Day,9510751,CDM,412,RC,94660,HCPCS,,,facility,both,,,,726,544.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Management Home Bipap Subseq Day,9510752,CDM,412,RC,94660,HCPCS,,,facility,both,,,,726,544.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Management Home Cpap Per Day,9510753,CDM,410,RC,94660,HCPCS,,,facility,both,,,,726,544.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-M-D Inhaler Initial,9510756,CDM,410,RC,94640,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-M-D Inhaler Treatment,9510757,CDM,410,RC,94640,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Nebulizer Sm. Vol Pentamidine Treatmt,9510760,CDM,410,RC,94642,HCPCS,,,facility,both,,,,414,310.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Oscillating Pep Therapy-Initial Tx,9510763,CDM,410,RC,94667,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Oscillating Pep Therapy-Subsequent Tx,9510764,CDM,410,RC,94668,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Oximetry Multiple Determinations,9510765,CDM,460,RC,94761,HCPCS,,,facility,both,,,,180,135,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Oximetry Multiple Determinations,9510765,CDM,460,RC,94761,HCPCS,,,facility,both,,,,206,154.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Rt-Oximetry Multiple Determinations,9510765,CDM,460,RC,94761,HCPCS,,,facility,both,,,,9,6.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Rt-Oximetry Standard Study,9510766,CDM,460,RC,94760,HCPCS,,,facility,both,,,,7,5.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Rt-Oximetry Standard Study,9510766,CDM,460,RC,94760,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Oximetry Standard Study,9510766,CDM,460,RC,94760,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Cardiopulmonary Exercise Testing,Inc Measuremnts Min Vent,Co2 Prod,02 Uptake,Electrocardio Record",9510773,CDM,460,RC,94621,HCPCS,,,facility,both,,,,983,737.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Cardiopulmonary Exercise Testing,Inc Measuremnts Min Vent,Co2 Prod,02 Uptake,Electrocardio Record",9510773,CDM,460,RC,94621,HCPCS,,,facility,both,,,,304,228,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Smoking And Tobacco Use Intensive Counseling, More Than 10 Minutes",9510776,CDM,942,RC,99407,HCPCS,,,facility,both,,,,111,83.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Smoking And Tobacco Use Intensive Counseling, More Than 10 Minutes",9510776,CDM,942,RC,99407,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Rt-Spirometry Pre/Post Broncodilator,9510777,CDM,460,RC,94060,HCPCS,,,facility,both,,,,569,426.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Spirometry Pre/Post Broncodilator,9510777,CDM,460,RC,94060,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Rt-Spirometry Screen W/Dilator Fvc/Fev,9510778,CDM,460,RC,94060,HCPCS,,,facility,both,,,,569,426.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Spirometry Screening Fvc/Fev,9510779,CDM,460,RC,94010,HCPCS,,,facility,both,,,,324,243,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Spirometry Screening Fvc/Fev,9510779,CDM,460,RC,94010,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Rt-Svn Initial Treatment,9510781,CDM,410,RC,94640,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Svn Subsq Treatment,9510782,CDM,410,RC,94640,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Vital Capacity,9510786,CDM,460,RC,94150,HCPCS,,,facility,both,,,,236,177,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt-Biofeedback Training,9510787,CDM,420,RC,90901,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt-Electrical Stimulation-Manual Ea 15Mi,9510790,CDM,420,RC,97032,HCPCS,,,facility,both,,,,114,85.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt-Electrical Stimulation-Modality,9510791,CDM,420,RC,97014,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Functional Activities Per 15Min,9510792,CDM,420,RC,97530,HCPCS,,,facility,both,,,,153,114.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Gait Training I Each 15Min,9510793,CDM,420,RC,97116,HCPCS,,,facility,both,,,,109,81.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt-Intermittent Compression Pump,9510794,CDM,420,RC,97016,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt-Iontophoresis Ea 15 Min,9510795,CDM,420,RC,97033,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt-Manual Therapy Techniques-Ea 15 Min,9510797,CDM,420,RC,97140,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Neuromuscular Re-Education Each 15Min,9510799,CDM,420,RC,97112,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Orthotic Mgmt/Train Ea 15 Min,9510800,CDM,420,RC,97760,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Prosthetic Training Ea 15 Min,9510802,CDM,420,RC,97761,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Therapeutic Exercise Per 15 Min,9510811,CDM,420,RC,97110,HCPCS,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt-Traction,9510813,CDM,420,RC,97012,HCPCS,,,facility,both,,,,94,70.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt-Ultrasound Each 15 Min,9510814,CDM,420,RC,97035,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot-Functional Activities 15 Min,9510826,CDM,430,RC,97530,HCPCS,,,facility,both,,,,153,114.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot-Manual Therapy Ea 15 Min,9510829,CDM,430,RC,97140,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot-Selective Debridement Up To First  20 Sq Cm,9510837,CDM,430,RC,97597,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ot-Sensory Integration, Ea 15 Min",9510839,CDM,430,RC,97533,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St-Pharyngogram/Vfss,9510849,CDM,444,RC,92611,HCPCS,,,facility,both,,,,571,428.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St-Swallow Treatment,9510850,CDM,440,RC,92526,HCPCS,,,facility,both,,,,320,240,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St-Ther Svcs Speech Gen Device,9510851,CDM,440,RC,92609,HCPCS,,,facility,both,,,,295,221.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc St-Treatment Speech/Language,9510852,CDM,440,RC,92507,HCPCS,,,facility,both,,,,320,240,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc St-Treatment Speech/Language, Group",9510853,CDM,443,RC,92508,HCPCS,,,facility,both,,,,188,141,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Audo-Comprehensive Audio Eval,9510856,CDM,471,RC,92557,HCPCS,,,facility,both,,,,220,165,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Audo-Hearing Test Air & Bone,9510861,CDM,471,RC,92553,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Audo-Oto-Acoustic Emissions Limited,9510864,CDM,471,RC,92587,HCPCS,,,facility,both,,,,288,216,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Audo-Oto-Acoustic Emissions Limited,9510864,CDM,471,RC,92587,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Audo-Tympanometry,9510868,CDM,471,RC,92567,HCPCS,,,facility,both,,,,68,51,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Gil-Eso Funct/Rflx Nasal Cath Elct Plc,9510939,CDM,750,RC,91037,HCPCS,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Esophageal  Motility Study, Manometry",9510942,CDM,750,RC,91010,HCPCS,,,facility,both,,,,1208,906,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Esophageal  Motility Study, Manometry",9510942,CDM,750,RC,91010,HCPCS,,,facility,both,,,,518,388.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Poct-Transcutan Bilirubin,9510986,CDM,301,RC,88720,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Psc Lab 1080003 Unit Charge
C Poct-Transcutan Bilirubin,9510986,CDM,301,RC,88720,HCPCS,,,facility,both,,,,25,18.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Facility Visit,9510998,CDM,510,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Facility Visit,9510998,CDM,510,RC,99211,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Office/Outpatient Established High Mdm, If Using Time, 40 Minutes Or More",9511002,CDM,510,RC,99215,HCPCS,,,facility,both,,,,400,300,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Visit-Ed,Level I",9511003,CDM,450,RC,99281,HCPCS,,,facility,both,,,,339,254.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Visit-Ed,Level I",9511003,CDM,450,RC,99281,HCPCS,,,facility,both,,,,339,254.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Visit-Ed,Level Ii",9511004,CDM,450,RC,99282,HCPCS,,,facility,both,,,,579,434.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Visit-Ed,Level Ii",9511004,CDM,450,RC,99282,HCPCS,,,facility,both,,,,579,434.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Visit-Ed,Level Iii",9511005,CDM,450,RC,99283,HCPCS,,,facility,both,,,,1030,772.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Visit-Ed,Level Iii",9511005,CDM,450,RC,99283,HCPCS,,,facility,both,,,,1030,772.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Visit-Ed,Level Iv",9511006,CDM,450,RC,99284,HCPCS,,,facility,both,,,,1718,1288.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Visit-Ed,Level Iv",9511006,CDM,450,RC,99284,HCPCS,,,facility,both,,,,1718,1288.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Visit-Ed,Level V",9511007,CDM,450,RC,99285,HCPCS,,,facility,both,,,,2939,2204.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Visit-Ed,Level V",9511007,CDM,450,RC,99285,HCPCS,,,facility,both,,,,2939,2204.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Visit-Ed,Level Vi",9511008,CDM,450,RC,99291,HCPCS,,,facility,both,,,,4890,3667.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Or-Surg Level 1 Addl 15 Minutes,9511110,CDM,360,RC,,,,,facility,both,,,,1505,1128.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Surg Level 1 First 15 Minutes,9511111,CDM,360,RC,,,,,facility,both,,,,1505,1128.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Surg Level 2 Addl 15 Minutes,9511112,CDM,360,RC,,,,,facility,both,,,,1920,1440,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Surg Level 2 First 15 Minutes,9511113,CDM,360,RC,,,,,facility,both,,,,1920,1440,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Surg Level 3 Addl 15 Minutes,9511114,CDM,360,RC,,,,,facility,both,,,,2108,1581,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Surg Level 3 First 15 Minutes,9511115,CDM,360,RC,,,,,facility,both,,,,2108,1581,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Surg Level 4 Addl 15 Minutes,9511116,CDM,360,RC,,,,,facility,both,,,,2408,1806,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Surg Level 4 First 15 Minutes,9511117,CDM,360,RC,,,,,facility,both,,,,2408,1806,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Surg Level 5 Addl 15 Minutes,9511118,CDM,360,RC,,,,,facility,both,,,,2593,1944.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Surg Level 5 First 15 Minutes,9511119,CDM,360,RC,,,,,facility,both,,,,2593,1944.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pacu-Phase 2 Recov 15 Min,9511130,CDM,710,RC,,,,,facility,both,,,,480,360,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Pacu-Phase 1 Recov 15 Min,9511132,CDM,710,RC,,,,,facility,both,,,,622,466.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Mhoc-Chemo Inf Ea Addl Hr,9511176,CDM,335,RC,96415,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Chemo Iv Inf To 1Hr Ini,9511177,CDM,335,RC,96413,HCPCS,,,facility,both,,,,1261,945.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Chemo Ad Iv Push Addl,9511178,CDM,331,RC,96411,HCPCS,,,facility,both,,,,526,394.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Chemo Ad Iv Push Init,9511179,CDM,331,RC,96409,HCPCS,,,facility,both,,,,697,522.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Chemo Inf Add Seqto 1Hr,9511180,CDM,335,RC,96417,HCPCS,,,facility,both,,,,526,394.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Pulm Reh Group 2 Or More Individuals,9511185,CDM,410,RC,G0239,HCPCS,,,facility,both,,,,196,147,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Cont Tx W/Aero Med 1St Hr,9511187,CDM,412,RC,94644,HCPCS,,,facility,both,,,,272,204,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Pul Imp Resp Fx 1/1 15M,9511188,CDM,410,RC,G0238,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Contx W/Aero Med Ea Add,9511190,CDM,412,RC,94645,HCPCS,,,facility,both,,,,201,150.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Pul Reh Stgth/End 1/1 15M,9511191,CDM,410,RC,G0237,HCPCS,,,facility,both,,,,138,103.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Intra Surf Adm Thru Endo,9511192,CDM,412,RC,94610,HCPCS,,,facility,both,,,,263,197.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Aquatic Therapy 15Min,9511332,CDM,420,RC,97113,HCPCS,,,facility,both,,,,145,108.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ot-Adl Training-15Min,9511334,CDM,430,RC,97535,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Flexible Endoscopic Eval Swallow C/V Rec,9511338,CDM,444,RC,92612,HCPCS,,,facility,both,,,,528,396,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St-Adapt/Trn Non-Sp Gen Dev,9511341,CDM,440,RC,92606,HCPCS,,,facility,both,,,,285,213.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot-Comm/Wk/Reint/Trng Per 15,9511343,CDM,430,RC,97537,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mbop-App Cast Elb-Fing,9511359,CDM,761,RC,29075,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Mbop-App Cast Shldr-Hands,9511361,CDM,761,RC,29065,HCPCS,,,facility,both,,,,263,197.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Mbop-App Cast Shldr-Hands,9511361,CDM,761,RC,29065,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Application Of Fingr Splint, Static",9511364,CDM,761,RC,29130,HCPCS,,,facility,both,,,,230,172.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Application Of Long Arm Splint (Shoulder To Hand),9511368,CDM,761,RC,29105,HCPCS,,,facility,both,,,,457,342.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Application Of Long Arm Splint (Shoulder To Hand),9511368,CDM,761,RC,29105,HCPCS,,,facility,both,,,,149,111.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Application Of Long Leg Splint (Thigh To Ankle Or Toes),9511369,CDM,761,RC,29505,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Application Of Short Arm Splint (Forearm To Hand), Static",9511370,CDM,761,RC,29125,HCPCS,,,facility,both,,,,122,91.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Mbop-App Shrt Leg Cast,9511371,CDM,761,RC,29405,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Application Of Short Leg Splint (Calf To Foot),9511373,CDM,761,RC,29515,HCPCS,,,facility,both,,,,487,365.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Application Of Short Leg Splint (Calf To Foot),9511373,CDM,761,RC,29515,HCPCS,,,facility,both,,,,149,111.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Mbop-Rmv/Bivalv Full Arm/Leg,9511376,CDM,761,RC,29705,HCPCS,,,facility,both,,,,351,263.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Mbop-Rmv/Bi Gntlt/Boot/Body,9511377,CDM,761,RC,29700,HCPCS,,,facility,both,,,,362,271.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Rt-Tube Chg Bef Est Fist Tr,9511382,CDM,361,RC,31502,HCPCS,,,facility,both,,,,518,388.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Tube Chg Bef Est Fist Tr,9511382,CDM,361,RC,31502,HCPCS,,,facility,both,,,,450,337.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Event Montr 24Hr Attend,9511408,CDM,730,RC,93270,HCPCS,,,facility,both,,,,100,75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ephys-Intracard 3D Mapping,9511437,CDM,480,RC,93613,HCPCS,,,facility,both,,,,8366,6274.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us-Fetal Echocardiography,9511700,CDM,402,RC,76825,HCPCS,,,facility,both,,,,1359,1019.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt-Work Hard/Cond Init 2Hrs,9511702,CDM,420,RC,97545,HCPCS,,,facility,both,,,,362,271.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Dbe Gluc Mntr Cont Rec From Interstitial Tiss Fluid,9512114,CDM,920,RC,95250,HCPCS,,,facility,both,,,,358,268.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Pt-Hot Or Cold Packs Therapy,9512117,CDM,420,RC,97010,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot-Hot Or Cold Packs Therapy,9512118,CDM,430,RC,97010,HCPCS,,,facility,both,,,,37,27.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Central/Periph Blood Draw,9512123,CDM,761,RC,36592,HCPCS,,,facility,both,,,,304,228,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Immune Admin Oral/Nasal Hb,9512147,CDM,771,RC,90473,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Electroencephalogram Cere Death Eval Only,9512285,CDM,740,RC,95824,HCPCS,,,facility,both,,,,1662,1246.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Injection(S), Anesthetic Agent(S) And/Or Steroid, Suprascapular Nerve",9512286,CDM,490,RC,64418,HCPCS,,,facility,both,,,,1637,1227.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Needle Electromyography 1 Extremity With Or Without Related Paraspinal Areas,9512287,CDM,922,RC,95860,HCPCS,,,facility,both,,,,385,288.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Needle Electromyography 1 Extremity With Or Without Related Paraspinal Areas,9512287,CDM,922,RC,95860,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Needle Electromyography 2 Extremities With Or Without Related Paraspinal Areas,9512288,CDM,922,RC,95861,HCPCS,,,facility,both,,,,171,128.25,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
C Needle Electromyography 2 Extremities With Or Without Related Paraspinal Areas,9512288,CDM,922,RC,95861,HCPCS,,,facility,both,,,,171,128.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Chemodenervation Of Muscle Innervated By Facial Nerve, Unilateral",9512294,CDM,361,RC,64612,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Chemodenervation Of Muscle Innervated By Facial Nerve, Unilateral",9512294_50,CDM,361,RC,64612,HCPCS,,,facility,both,,,50,411,308.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Office/Outpatient Established Minimal Problem(S),9512298,CDM,510,RC,99211,HCPCS,,,facility,both,,,,221,165.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Office/Outpatient Established Sf Mdm, If Using Time, 10 Minutes Or More",9512299,CDM,510,RC,99212,HCPCS,,,facility,both,,,,227,170.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Office/Outpatient Established Sf Mdm, If Using Time, 10 Minutes Or More",9512299,CDM,510,RC,99212,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Office/Outpatient Established Low Mdm, If Using Time, 20 Minutes Or More",9512300,CDM,510,RC,99213,HCPCS,,,facility,both,,,,263,197.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Office/Outpatient Established Low Mdm, If Using Time, 20 Minutes Or More",9512300,CDM,510,RC,99213,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Office/Outpatient Established Mod Mdm, If Using Time, 30 Minutes Or More",9512301,CDM,510,RC,99214,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Removal Iabp, Perc",9512304,CDM,361,RC,33968,HCPCS,,,facility,both,,,,1576,1182,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Biopsy Of Breast, Needle Core",9512312,CDM,361,RC,19100,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Inject For Retrograde Urethocysto,9512466,CDM,361,RC,51610,HCPCS,,,facility,both,,,,476,357,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Electronic Analysis Of Programmable, Implanted Pump For Intrathecal Or Epidural Drug Infusion, Inc",9512496,CDM,361,RC,62368,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Electrical Stimulation For Guidance In Conjunction With Chemodenervation,9512498,CDM,922,RC,95873,HCPCS,,,facility,both,,,,408,306,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Rt-Intub Et Emerg,9512499,CDM,410,RC,31500,HCPCS,,,facility,both,,,,1213,909.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Rt-Cath Asp Nasotrach,9512500,CDM,410,RC,31720,HCPCS,,,facility,both,,,,313,234.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Demo/Eval M-D-Inh W/ Ini Same Day (1/Day),9512503,CDM,410,RC,94664,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Demo/Eval Svn W/ Ini Same Day (1/Day),9512505,CDM,410,RC,94664,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Therapeutic Plasmapheresis,9512506,CDM,361,RC,36514,HCPCS,,,facility,both,,,,2943,2207.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ed-Insert Temp Bladder Catheter (Foley),9512508,CDM,450,RC,51702,HCPCS,,,facility,both,,,,306,229.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Pacemaker Interrog In Person,9512512,CDM,480,RC,93288,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Icd Interrog In Person,9512513,CDM,480,RC,93289,HCPCS,,,facility,both,,,,124,93,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc  Echo Tthrc R-T 2D W/Wom-Mode Compl Spec&Colr D Wo/ Contrast,9512516,CDM,483,RC,93306,HCPCS,,,facility,both,,,,1438,1078.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc  Echo Tthrc R-T 2D W/Wom-Mode Compl Spec&Colr D Wo/ Contrast,9512516,CDM,483,RC,93306,HCPCS,,,facility,both,,,,2168,1626,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Canalith Repositioning Proc,9512525,CDM,420,RC,95992,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Drain Pilonidal Cyst Simple,9512527,CDM,361,RC,10080,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Drain Pilonidal Cyst Simple,9512527,CDM,361,RC,10080,HCPCS,,,facility,both,,,,730,547.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Drain Pilonidal Cyst Simple,9512527,CDM,361,RC,10080,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Exc Cyst/Aberrant Breast Tissue Open 1/> Les,9512529,CDM,361,RC,19120,HCPCS,,,facility,both,,,,3309,2481.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ligation Of Hemorrhoid(S),9512536,CDM,361,RC,46221,HCPCS,,,facility,both,,,,832,624,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Insertion Of Temporary Indwelling Bladder Catheter; Complicated,9512539,CDM,761,RC,51703,HCPCS,,,facility,both,,,,472,354,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Scope Bladder/Urethra,For Dx",9512544,CDM,361,RC,52000,HCPCS,,,facility,both,,,,1772,1329,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Destruction Benign Lesion,9512551,CDM,361,RC,17110,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Excision Nail/Nail Matrix, Partial/Complete",9512552,CDM,361,RC,11750,HCPCS,,,facility,both,,,,562,421.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Excision Nail/Nail Matrix, Partial/Complete",9512552,CDM,361,RC,11750,HCPCS,,,facility,both,,,,562,421.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Excision Nail/Nail Matrix, Partial/Complete",9512552,CDM,361,RC,11750,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Capsulotomy, Synovectomy Of Toe",9512556,CDM,361,RC,28092,HCPCS,,,facility,both,,,,5119,3839.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Rem Foreign Body, Foot (Subcu)",9512558,CDM,361,RC,28190,HCPCS,,,facility,both,,,,1276,957,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Rem Foreign Body, Foot (Subcu)",9512558,CDM,361,RC,28190,HCPCS,,,facility,both,,,,1467,1100.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Removal Hardware, Superficial",9512559,CDM,361,RC,20670,HCPCS,,,facility,both,,,,5964,4473,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Rem Hardware, Deep",9512560,CDM,361,RC,20680,HCPCS,,,facility,both,,,,3473,2604.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nitric Oxide Expired Gas Determ,9512561,CDM,460,RC,95012,HCPCS,,,facility,both,,,,38,28.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Bronchoscopy Rigid Or Flexible, Inc Fluoro Guidance When Performed, With Computer-Assisted Image",9512563,CDM,361,RC,31627,HCPCS,,,facility,both,,,,208,156,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pne-Ip Lactation Consult & Teaching Per 30 Min,9512580,CDM,942,RC,S9443,HCPCS,,,facility,both,,,,215,161.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nasal Endoscopy Uni Or Bilat,9512581,CDM,361,RC,31231,HCPCS,,,facility,both,,,,417,312.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Nasal Endoscopy Uni Or Bilat,9512581,CDM,361,RC,31231,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Removal Foreign Body, Intranasal; Office Type Procedure",9512583,CDM,361,RC,30300,HCPCS,,,facility,both,,,,366,274.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Control Nasal Hemorrhage, Anterior, Simple (Limited Cautery And/Or Packing) Any Method",9512584,CDM,361,RC,30901,HCPCS,,,facility,both,,,,394,295.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Control Nasal Hemorrhage, Anterior, Simple (Limited Cautery And/Or Packing) Any Method",9512584,CDM,361,RC,30901,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Laryngoscopy Flexible Diagnostic,9512586,CDM,361,RC,31575,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Laryngoscopy Flexible Diagnostic,9512586,CDM,361,RC,31575,HCPCS,,,facility,both,,,,600,450,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Nasopharyngoscopy With Endoscope (Separate Procedure),9512587,CDM,361,RC,92511,HCPCS,,,facility,both,,,,342,256.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Nasopharyngoscopy With Endoscope (Separate Procedure),9512587,CDM,361,RC,92511,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Removal Impacted Cerumen Requiring Instrumentation, Unilateral",9512595,CDM,361,RC,69210,HCPCS,,,facility,both,,,,222,166.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Removal Impacted Cerumen Requiring Instrumentation, Unilateral",9512595,CDM,361,RC,69210,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Removal Impacted Cerumen Requiring Instrumentation, Unilateral",9512595_50,CDM,361,RC,69210,HCPCS,,,facility,both,,,50,513,384.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
"C Removal Impacted Cerumen Requiring Instrumentation, Unilateral",9512595_50,CDM,361,RC,69210,HCPCS,,,facility,both,,,50,89,66.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
C Removal Foreign Body From External Auditory Canal; Without General Anesthesia,9512596,CDM,361,RC,69200,HCPCS,,,facility,both,,,,306,229.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Removal Foreign Body From External Auditory Canal; Without General Anesthesia,9512596,CDM,361,RC,69200,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Eye For Foreign Body,9512628,CDM,320,RC,70030,HCPCS,,,facility,both,,,,246,184.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Mandible 4+ View Complete,9512634,CDM,320,RC,70110,HCPCS,,,facility,both,,,,322,241.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Facial Bones < 3 View Limited,9512643,CDM,320,RC,70140,HCPCS,,,facility,both,,,,322,241.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Facial Bones 3+ View Complete,9512646,CDM,320,RC,70150,HCPCS,,,facility,both,,,,422,316.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Nasal Bones,9512649,CDM,320,RC,70160,HCPCS,,,facility,both,,,,465,348.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Orbits 4+ View Complete,9512655,CDM,320,RC,70200,HCPCS,,,facility,both,,,,354,265.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Sinuses < 3 View Limited,9512658,CDM,320,RC,70210,HCPCS,,,facility,both,,,,354,265.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Sinuses 3+ View Complete,9512661,CDM,320,RC,70220,HCPCS,,,facility,both,,,,354,265.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Skull < 4 View Limited,9512667,CDM,320,RC,70250,HCPCS,,,facility,both,,,,425,318.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Skull 4+ View Complete,9512670,CDM,320,RC,70260,HCPCS,,,facility,both,,,,512,384,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Tmj Bilateral,9512676,CDM,320,RC,70330,HCPCS,,,facility,both,,,,323,242.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Tmj(S),9512679,CDM,610,RC,70336,HCPCS,,,facility,both,,,,1846,1384.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Soft Tissue Neck,9512682,CDM,320,RC,70360,HCPCS,,,facility,both,,,,421,315.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Radiologic Exam Swallow Function Contrast Study,9512685,CDM,320,RC,74230,HCPCS,,,facility,both,,,,522,391.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Head W/O Contrast,9512694,CDM,351,RC,70450,HCPCS,,,facility,both,,,,1535,1151.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Head W/ Contrast,9512697,CDM,351,RC,70460,HCPCS,,,facility,both,,,,1710,1282.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Head W/&W/O Contrast,9512700,CDM,351,RC,70470,HCPCS,,,facility,both,,,,1752,1314,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Orbit Sella Post Fossa Wo,9512703,CDM,351,RC,70480,HCPCS,,,facility,both,,,,1680,1260,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Orbit Sella Post Fossa W,9512706,CDM,351,RC,70481,HCPCS,,,facility,both,,,,2040,1530,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Orbit Sella Post Fossa W&W/O,9512709,CDM,351,RC,70482,HCPCS,,,facility,both,,,,2160,1620,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ct Maxilla/Facial W/O Contrast,9512712,CDM,351,RC,70486,HCPCS,,,facility,both,,,,1556,1167,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Maxilla/Facial W/ Contrast,9512715,CDM,351,RC,70487,HCPCS,,,facility,both,,,,1850,1387.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Maxilla/Facial W/&W/O Contrast,9512718,CDM,351,RC,70488,HCPCS,,,facility,both,,,,2000,1500,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Soft Tissue Neck W/O Contrast,9512721,CDM,351,RC,70490,HCPCS,,,facility,both,,,,1440,1080,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Soft Tissue Neck W/ Contrast,9512724,CDM,351,RC,70491,HCPCS,,,facility,both,,,,2099,1574.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Soft Tissue Neck W/&W/O Contrast,9512727,CDM,351,RC,70492,HCPCS,,,facility,both,,,,2185,1638.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Angio Head W/&W/O Contrast,9512730,CDM,351,RC,70496,HCPCS,,,facility,both,,,,2100,1575,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Angio Neck W/&W/O Contrast,9512733,CDM,351,RC,70498,HCPCS,,,facility,both,,,,2100,1575,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Orbit Face & Neck W/O Cont,9512736,CDM,611,RC,70540,HCPCS,,,facility,both,,,,1899,1424.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Orbit Face And Neck W/ Contrast,9512739,CDM,611,RC,70542,HCPCS,,,facility,both,,,,2493,1869.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Orbit Face And Neck W/&W/O Contrast,9512742,CDM,611,RC,70543,HCPCS,,,facility,both,,,,3024,2268,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mra Head W/O Contrast,9512745,CDM,615,RC,70544,HCPCS,,,facility,both,,,,2004,1503,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mra Head W/ Contrast,9512748,CDM,615,RC,70545,HCPCS,,,facility,both,,,,2351,1763.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mra Head W/&W/O Contrast,9512751,CDM,615,RC,70546,HCPCS,,,facility,both,,,,3153,2364.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mra Neck W/O Contrast,9512754,CDM,615,RC,70547,HCPCS,,,facility,both,,,,1846,1384.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mra Neck W/ Contrast,9512757,CDM,615,RC,70548,HCPCS,,,facility,both,,,,2659,1994.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mra Neck W/&W/O Contrast,9512760,CDM,615,RC,70549,HCPCS,,,facility,both,,,,3252,2439,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mri Head W/O Contrast,9512763,CDM,611,RC,70551,HCPCS,,,facility,both,,,,2127,1595.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Head W/ Contrast,9512767,CDM,611,RC,70552,HCPCS,,,facility,both,,,,2308,1731,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Head W/&W/O Contrast,9512770,CDM,611,RC,70553,HCPCS,,,facility,both,,,,2766,2074.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Ribs Unilateral 2 View No Chest,9512800,CDM,320,RC,71100,HCPCS,,,facility,both,,,,381,285.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Ribs Unilateral 3+ View With Chest,9512803,CDM,320,RC,71101,HCPCS,,,facility,both,,,,394,295.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Ribs Bilateral 3 View No Chest,9512806,CDM,320,RC,71110,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Ribs Bilateral 4+ View With Chest,9512809,CDM,320,RC,71111,HCPCS,,,facility,both,,,,630,472.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Sternum,9512812,CDM,320,RC,71120,HCPCS,,,facility,both,,,,354,265.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Sternum,9512812,CDM,320,RC,71120,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Sternoclavicular Joints,9512815,CDM,320,RC,71130,HCPCS,,,facility,both,,,,293,219.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Sternoclavicular Joints,9512815,CDM,320,RC,71130,HCPCS,,,facility,both,,,,93,69.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Computed Tomography, Thorax, Diagnostic; Without Contrast Material",9512820,CDM,352,RC,71250,HCPCS,,,facility,both,,,,1200,900,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Computed Tomography, Thorax, Diagnostic; With Contrast Material(S)",9512821,CDM,352,RC,71260,HCPCS,,,facility,both,,,,1817,1362.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Computed Tomography, Thorax, Diagnostic; Without Contrast Material, Followed By Contrast Material",9512824,CDM,352,RC,71270,HCPCS,,,facility,both,,,,1900,1425,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Angio Chest W/&W/O Contrast,9512827,CDM,352,RC,71275,HCPCS,,,facility,both,,,,2150,1612.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Chest W/O Contrast,9512830,CDM,610,RC,71550,HCPCS,,,facility,both,,,,2026,1519.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Chest W/&W/O Contrast,9512833,CDM,610,RC,71552,HCPCS,,,facility,both,,,,2875,2156.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Spine 1 View (Specify Level),9512836,CDM,320,RC,72020,HCPCS,,,facility,both,,,,315,236.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Xr Cspine 2-3 View - Ap, Lat",9512839,CDM,320,RC,72040,HCPCS,,,facility,both,,,,256,192,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Xr Cspine 2-3 View - Ap, Lat",9512839,CDM,320,RC,72040,HCPCS,,,facility,both,,,,256,192,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Tspine 2 View - Ap, Lat",9512851,CDM,320,RC,72070,HCPCS,,,facility,both,,,,229,171.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Tspine 3 View, Complete",9512854,CDM,320,RC,72072,HCPCS,,,facility,both,,,,346,259.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Tspine 4+ View W/ Obliques,9512857,CDM,320,RC,72074,HCPCS,,,facility,both,,,,459,344.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Tspine 4+ View W/ Obliques,9512857,CDM,320,RC,72074,HCPCS,,,facility,both,,,,459,344.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Xr Tspine/Lspine 2 View - Ap, Lat",9512860,CDM,320,RC,72080,HCPCS,,,facility,both,,,,321,240.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Lspine 2-3 View - Ap, Lat",9512866,CDM,320,RC,72100,HCPCS,,,facility,both,,,,256,192,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Lspine 2-3 View - Ap, Lat",9512866,CDM,320,RC,72100,HCPCS,,,facility,both,,,,256,192,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Lspine 4+ View,9512869,CDM,320,RC,72110,HCPCS,,,facility,both,,,,507,380.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Xr Lspine 4+ View,9512869,CDM,320,RC,72110,HCPCS,,,facility,both,,,,507,380.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Lspine 4+ View,9512869,CDM,320,RC,72110,HCPCS,,,facility,both,,,,507,380.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Xr Lspine W/ Bending, Minimum Of 6 Views",9512872,CDM,320,RC,72114,HCPCS,,,facility,both,,,,508,381,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Xr Lspine W/ Bending, Minimum Of 6 Views",9512872,CDM,320,RC,72114,HCPCS,,,facility,both,,,,508,381,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Xr Lspine W/ Bending, Minimum Of 6 Views",9512872,CDM,320,RC,72114,HCPCS,,,facility,both,,,,508,381,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Lspine Bending  2 Or 3 Views,9512875,CDM,320,RC,72120,HCPCS,,,facility,both,,,,322,241.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Cspine W/O Contrast,9512878,CDM,352,RC,72125,HCPCS,,,facility,both,,,,1150,862.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Cspine W/ Contrast,9512881,CDM,352,RC,72126,HCPCS,,,facility,both,,,,1427,1070.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Cspine W/&W/O Contrast,9512884,CDM,352,RC,72127,HCPCS,,,facility,both,,,,1500,1125,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Tspine W/O Contrast,9512887,CDM,352,RC,72128,HCPCS,,,facility,both,,,,1175,881.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Tspine W/ Contrast,9512890,CDM,352,RC,72129,HCPCS,,,facility,both,,,,1870,1402.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Tspine W/&W/O Contrast,9512893,CDM,352,RC,72130,HCPCS,,,facility,both,,,,1970,1477.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Lspine W/O Contrast,9512896,CDM,352,RC,72131,HCPCS,,,facility,both,,,,1175,881.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Lspine W/ Contrast,9512899,CDM,352,RC,72132,HCPCS,,,facility,both,,,,1896,1422,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Lspine W/&W/O Contrast,9512902,CDM,352,RC,72133,HCPCS,,,facility,both,,,,1990,1492.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Cspine W/O Contrast,9512905,CDM,612,RC,72141,HCPCS,,,facility,both,,,,2127,1595.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Cspine W/ Contrast,9512908,CDM,612,RC,72142,HCPCS,,,facility,both,,,,2420,1815,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Tspine W/O Contrast,9512911,CDM,612,RC,72146,HCPCS,,,facility,both,,,,2127,1595.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Tspine W/ Contrast,9512914,CDM,612,RC,72147,HCPCS,,,facility,both,,,,2351,1763.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Lspine W/O Contrast,9512917,CDM,612,RC,72148,HCPCS,,,facility,both,,,,2026,1519.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Lspine W/ Contrast,9512920,CDM,612,RC,72149,HCPCS,,,facility,both,,,,2351,1763.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Cspine W/&W/O Contrast,9512923,CDM,612,RC,72156,HCPCS,,,facility,both,,,,3311,2483.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Tspine W/&W/O Contrast,9512926,CDM,612,RC,72157,HCPCS,,,facility,both,,,,3311,2483.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Lspine W/&W/O Contrast,9512929,CDM,612,RC,72158,HCPCS,,,facility,both,,,,3153,2364.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Pelvis 1-2 View,9512935,CDM,320,RC,72170,HCPCS,,,facility,both,,,,322,241.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Pelvis 1-2 View,9512935,CDM,320,RC,72170,HCPCS,,,facility,both,,,,322,241.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Pelvis 3+ View, Complete (Specify Views)",9512938,CDM,320,RC,72190,HCPCS,,,facility,both,,,,229,171.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Angio Pelvis W/&W/O Iv Contrast,9512941,CDM,352,RC,72191,HCPCS,,,facility,both,,,,1650,1237.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Pelvis W/O Iv Contrast,9512944,CDM,352,RC,72192,HCPCS,,,facility,both,,,,1575,1181.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Pelvis W/ Iv Contrast,9512947,CDM,352,RC,72193,HCPCS,,,facility,both,,,,1900,1425,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Pelvis W/&W/O Iv Contrast,9512950,CDM,352,RC,72194,HCPCS,,,facility,both,,,,1950,1462.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Pelvis W/O Contrast,9512953,CDM,610,RC,72195,HCPCS,,,facility,both,,,,2127,1595.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Pelvis W/ Contrast,9512956,CDM,610,RC,72196,HCPCS,,,facility,both,,,,2404,1803,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Pelvis W/&W/O Contrast,9512959,CDM,610,RC,72197,HCPCS,,,facility,both,,,,3635,2726.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Sacroilliac < 3 View,9512962,CDM,320,RC,72200,HCPCS,,,facility,both,,,,362,271.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Sacroilliac 3+ View,9512965,CDM,320,RC,72202,HCPCS,,,facility,both,,,,425,318.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Sacrum/Coccyx,9512968,CDM,320,RC,72220,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Sacrum/Coccyx,9512968,CDM,320,RC,72220,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Clavicle,9512992,CDM,320,RC,73000,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Clavicle,9512992,CDM,320,RC,73000,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Scapula,9512995,CDM,320,RC,73010,HCPCS,,,facility,both,,,,337,252.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Scapula,9512995,CDM,320,RC,73010,HCPCS,,,facility,both,,,,337,252.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Shoulder 1 View,9512998,CDM,320,RC,73020,HCPCS,,,facility,both,,,,284,213,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Shoulder 1 View,9512998,CDM,320,RC,73020,HCPCS,,,facility,both,,,,284,213,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Shoulder 2+ View, Complete",9513001,CDM,320,RC,73030,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Shoulder 2+ View, Complete",9513001,CDM,320,RC,73030,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Arthrogram Shoulder,9513004,CDM,322,RC,73040,HCPCS,,,facility,both,,,,1060,795,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Acromioclavicular Joints Bilateral,9513007,CDM,320,RC,73050,HCPCS,,,facility,both,,,,262,196.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Acromioclavicular Joints Bilateral,9513007,CDM,320,RC,73050,HCPCS,,,facility,both,,,,262,196.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Humerus,9513010,CDM,320,RC,73060,HCPCS,,,facility,both,,,,257,192.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Humerus,9513010,CDM,320,RC,73060,HCPCS,,,facility,both,,,,257,192.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Elbow 2 View - Ap, Lat",9513013,CDM,320,RC,73070,HCPCS,,,facility,both,,,,280,210,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Elbow 2 View - Ap, Lat",9513013,CDM,320,RC,73070,HCPCS,,,facility,both,,,,280,210,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Elbow 3+ View, Complete",9513016,CDM,320,RC,73080,HCPCS,,,facility,both,,,,337,252.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Elbow 3+ View, Complete",9513016,CDM,320,RC,73080,HCPCS,,,facility,both,,,,337,252.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Arthrogram Elbow,9513019,CDM,322,RC,73085,HCPCS,,,facility,both,,,,1131,848.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Forearm,9513022,CDM,320,RC,73090,HCPCS,,,facility,both,,,,315,236.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Forearm,9513022,CDM,320,RC,73090,HCPCS,,,facility,both,,,,315,236.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Upr Ext 2+ View Infant,9513025,CDM,320,RC,73092,HCPCS,,,facility,both,,,,425,318.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Wrist 2 View - Ap, Lat",9513028,CDM,320,RC,73100,HCPCS,,,facility,both,,,,320,240,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Wrist 2 View - Ap, Lat",9513028,CDM,320,RC,73100,HCPCS,,,facility,both,,,,320,240,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Wrist 3+ View, Complete",9513031,CDM,320,RC,73110,HCPCS,,,facility,both,,,,364,273,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Wrist 3+ View, Complete",9513031,CDM,320,RC,73110,HCPCS,,,facility,both,,,,364,273,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Arthrogram Wrist,9513034,CDM,322,RC,73115,HCPCS,,,facility,both,,,,1159,869.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Hand 2 View - Ap, Lat",9513037,CDM,320,RC,73120,HCPCS,,,facility,both,,,,322,241.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Hand 2 View - Ap, Lat",9513037,CDM,320,RC,73120,HCPCS,,,facility,both,,,,322,241.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Hand 3+ View, Complete",9513040,CDM,320,RC,73130,HCPCS,,,facility,both,,,,337,252.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Hand 3+ View, Complete",9513040,CDM,320,RC,73130,HCPCS,,,facility,both,,,,337,252.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Fingers 2+ View,9513043,CDM,320,RC,73140,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Fingers 2+ View,9513043,CDM,320,RC,73140,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ct Upr Ext W/O Contrast,9513046,CDM,352,RC,73200,HCPCS,,,facility,both,,,,1488,1116,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Upr Ext W/ Contrast,9513049,CDM,352,RC,73201,HCPCS,,,facility,both,,,,1900,1425,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Upr Ext W/&W/O Contrast,9513052,CDM,352,RC,73202,HCPCS,,,facility,both,,,,2000,1500,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Angio Upr Ext W/&W/O Contrast,9513057,CDM,352,RC,73206,HCPCS,,,facility,both,,,,2376,1782,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Mri, Upper Extremities W/O",9513058,CDM,610,RC,73218,HCPCS,,,facility,both,,,,1927,1445.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Upr Ext Nc Joint W/ Contrast,9513061,CDM,610,RC,73219,HCPCS,,,facility,both,,,,2641,1980.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Upr Ext Nc Joint W/&W/O Contrast,9513064,CDM,610,RC,73220,HCPCS,,,facility,both,,,,3808,2856,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Upr Ext Joint W/O Contrast,9513067,CDM,610,RC,73221,HCPCS,,,facility,both,,,,2127,1595.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Mri Joint, Upper Extremity W/ Contrast",9513070,CDM,610,RC,73222,HCPCS,,,facility,both,,,,2712,2034,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Mri, Joint, Upper Extremity W/O And W/Contrast",9513073,CDM,610,RC,73223,HCPCS,,,facility,both,,,,3153,2364.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Arthrogram Hip,9513088,CDM,322,RC,73525,HCPCS,,,facility,both,,,,1162,871.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Knee 2 Views - Ap, Lat",9513100,CDM,320,RC,73560,HCPCS,,,facility,both,,,,301,225.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Knee 2 Views - Ap, Lat",9513100,CDM,320,RC,73560,HCPCS,,,facility,both,,,,301,225.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Xr Knee 3 View (Specify View 3),9513103,CDM,320,RC,73562,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Xr Knee 3 View (Specify View 3),9513103,CDM,320,RC,73562,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Knee 4+ View, Complete (Specify View 3 & 4)",9513106,CDM,320,RC,73564,HCPCS,,,facility,both,,,,330,247.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Knee 4+ View, Complete (Specify View 3 & 4)",9513106,CDM,320,RC,73564,HCPCS,,,facility,both,,,,330,247.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Knee 4+ View, Complete (Specify View 3 & 4)",9513106_50,CDM,320,RC,73564,HCPCS,,,facility,both,,,50,495,371.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
"C Xr Knees Bilateral 1 View - Ap, Standing",9513109,CDM,320,RC,73565,HCPCS,,,facility,both,,,,310,232.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Knees Bilateral 1 View - Ap, Standing",9513109,CDM,320,RC,73565,HCPCS,,,facility,both,,,,310,232.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Arthrogram Knee,9513112,CDM,322,RC,73580,HCPCS,,,facility,both,,,,1264,948,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Arthrogram Knee,9513112,CDM,322,RC,73580,HCPCS,,,facility,both,,,,1264,948,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Xr Tibia/Fibula 2 View,9513115,CDM,320,RC,73590,HCPCS,,,facility,both,,,,281,210.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Tibia/Fibula 2 View,9513115,CDM,320,RC,73590,HCPCS,,,facility,both,,,,281,210.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Lwr Ext 2+ View, Infant",9513118,CDM,320,RC,73592,HCPCS,,,facility,both,,,,295,221.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Ankle 2 View - Ap, Lat",9513121,CDM,320,RC,73600,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Ankle 2 View - Ap, Lat",9513121,CDM,320,RC,73600,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Ankle 3+ View, Complete",9513124,CDM,320,RC,73610,HCPCS,,,facility,both,,,,364,273,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Ankle 3+ View, Complete",9513124,CDM,320,RC,73610,HCPCS,,,facility,both,,,,364,273,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Foot 2 View - Ap, Lat",9513130,CDM,320,RC,73620,HCPCS,,,facility,both,,,,304,228,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Foot 2 View - Ap, Lat",9513130,CDM,320,RC,73620,HCPCS,,,facility,both,,,,304,228,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Foot 3+ View, Complete",9513133,CDM,320,RC,73630,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Foot 3+ View, Complete",9513133,CDM,320,RC,73630,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Heel 2+ View,9513136,CDM,320,RC,73650,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Heel 2+ View,9513136,CDM,320,RC,73650,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Toes 2+ View,9513139,CDM,320,RC,73660,HCPCS,,,facility,both,,,,231,173.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Xr Toes 2+ View,9513139,CDM,320,RC,73660,HCPCS,,,facility,both,,,,231,173.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Lwr Ext W/O Contrast,9513142,CDM,352,RC,73700,HCPCS,,,facility,both,,,,1246,934.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Lwr Ext W/ Contrast,9513145,CDM,352,RC,73701,HCPCS,,,facility,both,,,,1817,1362.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Lwr Ext W/ Contrast,9513145_50,CDM,352,RC,73701,HCPCS,,,facility,both,,,50,2725.5,2044.12,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
C Ct Lwr Ext W/&W/O Contrast,9513148,CDM,352,RC,73702,HCPCS,,,facility,both,,,,2086,1564.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Angio Lwr Ext W/&W/O Contrast,9513151,CDM,352,RC,73706,HCPCS,,,facility,both,,,,1690,1267.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Angio Lwr Ext W/&W/O Contrast,9513151_50,CDM,352,RC,73706,HCPCS,,,facility,both,,,50,2535,1901.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
C Mri Lwr Ext Nc Joint W/O Contrast,9513154,CDM,610,RC,73718,HCPCS,,,facility,both,,,,1927,1445.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Lwr Ext Nc Joint W/ Contrast,9513157,CDM,610,RC,73719,HCPCS,,,facility,both,,,,2641,1980.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Lwr Ext Nc Joint W/&W/O Contrast,9513160,CDM,610,RC,73720,HCPCS,,,facility,both,,,,2983,2237.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Lwr Ext Joint W/O Contrast,9513163,CDM,610,RC,73721,HCPCS,,,facility,both,,,,2127,1595.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Mri, Joint, Lower Extremity W/Contrast",9513166,CDM,610,RC,73722,HCPCS,,,facility,both,,,,2978,2233.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Lwr Ext Joint W/&W/O Contrast,9513169,CDM,610,RC,73723,HCPCS,,,facility,both,,,,3311,2483.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiologic Examination, Complete Acute Abdomen Series, Including 2 Or More Views Of The Abdomen (E",9513181,CDM,320,RC,74022,HCPCS,,,facility,both,,,,473,354.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Abdomen W/O Iv Contrast,9513184,CDM,352,RC,74150,HCPCS,,,facility,both,,,,1417,1062.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Abdomen W/ Iv Contrast,9513188,CDM,352,RC,74160,HCPCS,,,facility,both,,,,1710,1282.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Abdomen W/&W/O Iv Contrast,9513191,CDM,352,RC,74170,HCPCS,,,facility,both,,,,1908,1431,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Angio Abdomen W/&W/O Iv Contrast,9513194,CDM,352,RC,74175,HCPCS,,,facility,both,,,,2021,1515.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Abdomen W/O Contrast,9513197,CDM,610,RC,74181,HCPCS,,,facility,both,,,,2127,1595.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Abdomen W/ Contrast,9513200,CDM,610,RC,74182,HCPCS,,,facility,both,,,,2217,1662.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Abdomen W/&W/O Contrast,9513203,CDM,610,RC,74183,HCPCS,,,facility,both,,,,2973,2229.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiologic Examination, Esophagus, Including Scout Chest Radiograph(S) And Delayed Image(S), When",9513206,CDM,320,RC,74220,HCPCS,,,facility,both,,,,539,404.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiologic Examination, Upper Gastrointestinal Tract, Including Scout Abdominal Radiograph(S) And",9513212,CDM,320,RC,74240,HCPCS,,,facility,both,,,,662,496.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiologic Exam, Upper Gastrointestinal Tract, Including Scout Abdominal Radiograph(S) And Delayed",9513221,CDM,320,RC,74246,HCPCS,,,facility,both,,,,727,545.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiologic Examination, Small Intestine, Including Multiple Serial Images And Scout Abdominal Radi",9513230,CDM,320,RC,74250,HCPCS,,,facility,both,,,,592,444,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiologic Examination, Colon, Including Scout Abdominal Radiograph(S) And Delayed Image(S), When",9513236,CDM,320,RC,74270,HCPCS,,,facility,both,,,,650,487.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiologic Examination, Colon, Including Scout Abdominal Radiograph(S) And Delayed Image(S), When",9513239,CDM,320,RC,74280,HCPCS,,,facility,both,,,,800,600,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Cholangiogram Operative,9513245,CDM,320,RC,74300,HCPCS,,,facility,both,,,,943,707.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xr Endoscopy Biliary,9513257,CDM,320,RC,74328,HCPCS,,,facility,both,,,,1313,984.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xr Endoscopy Pancreatic,9513260,CDM,320,RC,74329,HCPCS,,,facility,both,,,,1039,779.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xr Endoscopy Biliary & Pancreatic,9513263,CDM,320,RC,74330,HCPCS,,,facility,both,,,,989,741.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xr Tube Placement Gastric W/ Fluoro,9513266,CDM,320,RC,74340,HCPCS,,,facility,both,,,,423,317.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Intraluminal Dilation Esophagus,9513269,CDM,320,RC,74360,HCPCS,,,facility,both,,,,183,137.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Ivp,9513275,CDM,320,RC,74400,HCPCS,,,facility,both,,,,852,639,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Pyelogram Retrograde,9513281,CDM,320,RC,74420,HCPCS,,,facility,both,,,,1058,793.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Urography, Antegrade, Radiological Supervision And Interpretation",9513284,CDM,320,RC,74425,HCPCS,,,facility,both,,,,889,666.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Cystogram,9513287,CDM,320,RC,74430,HCPCS,,,facility,both,,,,1084,813,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Retrograde Urethrocystography,9513290,CDM,320,RC,74450,HCPCS,,,facility,both,,,,989,741.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Cystogram Voiding,9513293,CDM,320,RC,74455,HCPCS,,,facility,both,,,,865,648.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Gu Dilation,9513302,CDM,320,RC,74485,HCPCS,,,facility,both,,,,1206,904.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Hysterosalpingogram,9513305,CDM,320,RC,74740,HCPCS,,,facility,both,,,,1206,904.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Heart W/O Contrast,9513308,CDM,610,RC,75557,HCPCS,,,facility,both,,,,2026,1519.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Heart W/&W/O Contrast,9513320,CDM,610,RC,75561,HCPCS,,,facility,both,,,,2746,2059.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aortography Thoracic Serialography Rs&I,9513332,CDM,323,RC,75605,HCPCS,,,facility,both,,,,5011,3758.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aortography Abdominal Serialography Rs&I,9513335,CDM,323,RC,75625,HCPCS,,,facility,both,,,,4145,3108.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Aortography, Abdominal Plus Bilat Iliofemoral Lwr Extremity, Cath, By Serialography Rs&I",9513338,CDM,323,RC,75630,HCPCS,,,facility,both,,,,5160,3870,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Angio Abdominal Aorta W/&W/O Contrast,9513341,CDM,352,RC,75635,HCPCS,,,facility,both,,,,2585,1938.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Angio Spinal Select,9513368,CDM,323,RC,75705,HCPCS,,,facility,both,,,,5484,4113,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angiography Extremity Bilateral Rs&I,9513374,CDM,323,RC,75716,HCPCS,,,facility,both,,,,5951,4463.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angio Visceral Select Or Supraselect,9513383,CDM,323,RC,75726,HCPCS,,,facility,both,,,,8464,6348,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angio Pelvis Select Or Supraselect,9513386,CDM,323,RC,75736,HCPCS,,,facility,both,,,,5152,3864,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angio Pulmonary Unilateral Select,9513389,CDM,323,RC,75741,HCPCS,,,facility,both,,,,4345,3258.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angio Pulmonary Bilateral Select,9513392,CDM,323,RC,75743,HCPCS,,,facility,both,,,,5635,4226.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angio Selective Each Addl Vessel,9513395,CDM,323,RC,75774,HCPCS,,,facility,both,,,,2400,1800,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Shuntogram Non Vascular,9513401,CDM,320,RC,75809,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Venogram Extremity Unilateral,9513404,CDM,320,RC,75820,HCPCS,,,facility,both,,,,1577,1182.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Venogram Extremity Bilateral,9513407,CDM,320,RC,75822,HCPCS,,,facility,both,,,,1754,1315.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Venogram Inferior Vena Cava,9513410,CDM,320,RC,75825,HCPCS,,,facility,both,,,,4050,3037.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Venogram Superior Vena Cava,9513413,CDM,320,RC,75827,HCPCS,,,facility,both,,,,2233,1674.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Venogram Renal Unilateral,9513416,CDM,320,RC,75831,HCPCS,,,facility,both,,,,682,511.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Venogram Hepatic W Hemodynamics,9513425,CDM,320,RC,75889,HCPCS,,,facility,both,,,,5272,3954,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Biopsy Transcatheter,9513466,CDM,320,RC,75970,HCPCS,,,facility,both,,,,3499,2624.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Change Percut Tube Or Drain Catheter,9513473,CDM,320,RC,75984,HCPCS,,,facility,both,,,,764,573,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Abscess Drainage,9513476,CDM,320,RC,75989,HCPCS,,,facility,both,,,,1736,1302,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xr Fluoroscopy Up To One Hour,9513479,CDM,320,RC,76000,HCPCS,,,facility,both,,,,760,570,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Abdomen Foreign Body Nose Tc Rectum, Ped",9513485,CDM,320,RC,76010,HCPCS,,,facility,both,,,,421,315.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Imaging Exam Abscess, Fistula Or Sinus Tract Study, S&I",9513488,CDM,320,RC,76080,HCPCS,,,facility,both,,,,906,679.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Xr Exam, Surgical Specimen",9513491,CDM,320,RC,76098,HCPCS,,,facility,both,,,,579,434.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc 3D Rendering W/Interp & Postprocess Supervision, W/O Postprocess On Diff Work Station",9513503,CDM,320,RC,76376,HCPCS,,,facility,both,,,,618,463.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc 3D Rendering W/Interp & Postprocess Supervision, With Postprocess On Diff Work Station",9513506,CDM,350,RC,76377,HCPCS,,,facility,both,,,,844,633,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Limited Or Localized Study,9513509,CDM,350,RC,76380,HCPCS,,,facility,both,,,,758,568.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Spectroscopy,9513512,CDM,610,RC,76390,HCPCS,,,facility,both,,,,2415,1811.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Cranial Echoencephelogram,9513515,CDM,402,RC,76506,HCPCS,,,facility,both,,,,513,384.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Soft Tissue Neck,9513518,CDM,402,RC,76536,HCPCS,,,facility,both,,,,640,480,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Us Soft Tissue Neck,9513518,CDM,402,RC,76536,HCPCS,,,facility,both,,,,640,480,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Us Soft Tissue Neck,9513518,CDM,402,RC,76536,HCPCS,,,facility,both,,,,640,480,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Chest,9513521,CDM,402,RC,76604,HCPCS,,,facility,both,,,,478,358.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Chest,9513521,CDM,402,RC,76604,HCPCS,,,facility,both,,,,478,358.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Us Abdominal,9513527,CDM,402,RC,76700,HCPCS,,,facility,both,,,,957,717.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Us Abdominal, Limited (Specify Area)",9513530,CDM,402,RC,76705,HCPCS,,,facility,both,,,,634,475.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Us Abdominal, Limited (Specify Area)",9513530,CDM,402,RC,76705,HCPCS,,,facility,both,,,,634,475.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Us Retroperitoneal,9513533,CDM,402,RC,76770,HCPCS,,,facility,both,,,,634,475.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Us Retroperitoneal, Limited",9513536,CDM,402,RC,76775,HCPCS,,,facility,both,,,,615,461.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Us Retroperitoneal, Limited",9513536,CDM,402,RC,76775,HCPCS,,,facility,both,,,,615,461.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Us Trnspl Kdn R-T Img +- Duplex Dop Std,9513539,CDM,402,RC,76776,HCPCS,,,facility,both,,,,658,493.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Spinal Canal,9513542,CDM,402,RC,76800,HCPCS,,,facility,both,,,,634,475.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Ob < 14 Weeks,9513545,CDM,402,RC,76801,HCPCS,,,facility,both,,,,483,362.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Ob < 14 Wks Addl Fetus,9513548,CDM,402,RC,76802,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Ob Complete > 14 Weeks,9513551,CDM,402,RC,76805,HCPCS,,,facility,both,,,,560,420,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Ob Complete > 14 Weeks Addl Fetus,9513554,CDM,402,RC,76810,HCPCS,,,facility,both,,,,302,226.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Ob Detailed Anatomic Survey,9513557,CDM,402,RC,76811,HCPCS,,,facility,both,,,,785,588.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Ob Detailed Anatomy Addl Fetus,9513560,CDM,402,RC,76812,HCPCS,,,facility,both,,,,410,307.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Fetal Nuchal Translucency 1St Gestation,9513563,CDM,402,RC,76813,HCPCS,,,facility,both,,,,362,271.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Fetal Nuchal Translucency Ea Addl Gestation,9513566,CDM,402,RC,76814,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Ob Limited,9513569,CDM,402,RC,76815,HCPCS,,,facility,both,,,,359,269.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Ob Limited,9513569,CDM,402,RC,76815,HCPCS,,,facility,both,,,,359,269.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Us Ob Follow-Up - Per Fetus,9513572,CDM,402,RC,76816,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Ob Follow-Up - Per Fetus,9513572,CDM,402,RC,76816,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Us Ob Transvaginal,9513575,CDM,402,RC,76817,HCPCS,,,facility,both,,,,420,315,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Ob Transvaginal,9513575,CDM,402,RC,76817,HCPCS,,,facility,both,,,,420,315,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Us Fetal Biophysical,9513578,CDM,402,RC,76818,HCPCS,,,facility,both,,,,854,640.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Fetal Biophysical Profile,9513581,CDM,402,RC,76819,HCPCS,,,facility,both,,,,544,408,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Umbilical Artery,9513584,CDM,402,RC,76820,HCPCS,,,facility,both,,,,287,215.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Middle Cerebral Artery Echo,9513587,CDM,402,RC,76821,HCPCS,,,facility,both,,,,287,215.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Transvaginal Non Obstetric,9513599,CDM,402,RC,76830,HCPCS,,,facility,both,,,,578,433.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Transvaginal Non Obstetric,9513599,CDM,402,RC,76830,HCPCS,,,facility,both,,,,578,433.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Us Hysterosonography,9513602,CDM,402,RC,76831,HCPCS,,,facility,both,,,,823,617.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Pelvis Non Ob,9513605,CDM,402,RC,76856,HCPCS,,,facility,both,,,,664,498,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Us Pelvis Limited, Non-Obstetric",9513608,CDM,402,RC,76857,HCPCS,,,facility,both,,,,514,385.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Us Pelvis Limited, Non-Obstetric",9513608,CDM,402,RC,76857,HCPCS,,,facility,both,,,,514,385.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Us Testicular,9513611,CDM,402,RC,76870,HCPCS,,,facility,both,,,,497,372.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Guid Vasc Acss Ptntl Acss,9513623,CDM,402,RC,76937,HCPCS,,,facility,both,,,,552,414,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Us Guid Vasc Acss Ptntl Acss,9513623,CDM,402,RC,76937,HCPCS,,,facility,both,,,,552,414,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ultrasonic Guidance For Needle Placement,9513629,CDM,402,RC,76942,HCPCS,,,facility,both,,,,757,567.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ultrasonic Guidance For Needle Placement,9513629,CDM,402,RC,76942,HCPCS,,,facility,both,,,,757,567.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Us Amniocentes,9513632,CDM,402,RC,76946,HCPCS,,,facility,both,,,,676,507,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Us Guide Radioelemt Plcmt,9513635,CDM,402,RC,76965,HCPCS,,,facility,both,,,,819,614.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Us Guidance Intraoperative,9513638,CDM,402,RC,76998,HCPCS,,,facility,both,,,,724,543,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Central Line Placement W/ Fluoro,9513641,CDM,320,RC,77001,HCPCS,,,facility,both,,,,705,528.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xr Fluoroscopic Guidance Needle Placement,9513644,CDM,320,RC,77002,HCPCS,,,facility,both,,,,522,391.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xr Fluoroscopic Guidance Needle Placement,9513644,CDM,320,RC,77002,HCPCS,,,facility,both,,,,522,391.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Xr Guidance Spine Inj,9513647,CDM,320,RC,77003,HCPCS,,,facility,both,,,,503,377.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ct Guide Needle Placement,9513653,CDM,350,RC,77012,HCPCS,,,facility,both,,,,1380,1035,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Guidance Tissue Ablation,9513656,CDM,350,RC,77013,HCPCS,,,facility,both,,,,1920,1440,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ct Guidance Radiation Therapy Flds Placement,9513659,CDM,350,RC,77014,HCPCS,,,facility,both,,,,341,255.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Bone Age Study,9513689,CDM,320,RC,77072,HCPCS,,,facility,both,,,,351,263.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Bone Length Study,9513692,CDM,320,RC,77073,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Bone Length Study,9513692,CDM,320,RC,77073,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Bone Survey, Complete",9513698,CDM,320,RC,77075,HCPCS,,,facility,both,,,,498,373.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Bone Survey, Infant",9513701,CDM,320,RC,77076,HCPCS,,,facility,both,,,,401,300.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Dexa Bone Density Study,9513704,CDM,320,RC,77080,HCPCS,,,facility,both,,,,355,266.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Bone Marrow Blood Supply,9513707,CDM,610,RC,77084,HCPCS,,,facility,both,,,,1698,1273.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Nm Thyroid For Metastases, Whole Body",9513725,CDM,341,RC,78018,HCPCS,,,facility,both,,,,1840,1380,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Nm Bone Marrow Imaging, Limited Area",9513731,CDM,341,RC,78102,HCPCS,,,facility,both,,,,1532,1149,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Lymph System Imaging,9513740,CDM,341,RC,78195,HCPCS,,,facility,both,,,,3703,2777.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Liver/Spleen Imaging,9513755,CDM,341,RC,78215,HCPCS,,,facility,both,,,,1638,1228.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Gastric Emptying Study,9513767,CDM,341,RC,78264,HCPCS,,,facility,both,,,,2353,1764.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Gi Bleed,9513770,CDM,341,RC,78278,HCPCS,,,facility,both,,,,3703,2777.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Nm Intestine Imaging, Meckels Divert Exam",9513773,CDM,341,RC,78290,HCPCS,,,facility,both,,,,1355,1016.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Nm Bone Imaging, Limited Area",9513776,CDM,341,RC,78300,HCPCS,,,facility,both,,,,2451,1838.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Nm Bone Imaging, Whole Body",9513779,CDM,341,RC,78306,HCPCS,,,facility,both,,,,2615,1961.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Nm Bone Imaging, 3 Phase",9513782,CDM,341,RC,78315,HCPCS,,,facility,both,,,,2390,1792.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Nm Gated Heart (Muga) Planar, Single",9513797,CDM,341,RC,78472,HCPCS,,,facility,both,,,,1573,1179.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Nm Gated Heart (Muga) Planar, Single",9513797,CDM,341,RC,78472,HCPCS,,,facility,both,,,,2300,1725,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Lung Perfusion,9513815,CDM,341,RC,78580,HCPCS,,,facility,both,,,,1337,1002.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Brain Ltd Imaging & Flow,9513836,CDM,341,RC,78601,HCPCS,,,facility,both,,,,1467,1100.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pet Brain,9513848,CDM,404,RC,78608,HCPCS,,,facility,both,,,,6514,4885.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Brain Vascular Flow Only,9513851,CDM,341,RC,78610,HCPCS,,,facility,both,,,,1467,1100.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Csf Flow Cisternogram,9513854,CDM,341,RC,78630,HCPCS,,,facility,both,,,,2689,2016.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Csf Shunt Evaluation,9513860,CDM,341,RC,78645,HCPCS,,,facility,both,,,,1434,1075.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Nm Renal W/ Vascular Flow W/O Lasix, Single",9513872,CDM,341,RC,78707,HCPCS,,,facility,both,,,,2560,1920,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Nm Renal W/ Vascular Flow W/ Lasix, Single",9513875,CDM,341,RC,78708,HCPCS,,,facility,both,,,,2380,1785,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiopharmaceutical Localization Of Tumor, Inflammatory Process Or Dist Of Radiopharmaceutical Age",9513890,CDM,341,RC,78800,HCPCS,,,facility,both,,,,2193,1644.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiopharmaceutical Localization Of Tumor, Inflamm Process Or Distrib Of Radiopharmaceutical Agent",9513893,CDM,341,RC,78802,HCPCS,,,facility,both,,,,3782,2836.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Radiopharmaceutical Localization Of Tumor, Inflammatory Process Or Distribution Of Radiopharmaceu",9513896,CDM,341,RC,78803,HCPCS,,,facility,both,,,,3703,2777.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiopharmaceutical Localization Of Tumor, Inflamm Process Or Distrib Of Radiopharmaceutical Agent",9513899,CDM,341,RC,78804,HCPCS,,,facility,both,,,,4761,3570.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Radiopharm Local Iv Inject Only,9513911,CDM,341,RC,78808,HCPCS,,,facility,both,,,,927,695.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pet Skull To Mid-Thigh,9513915,CDM,404,RC,78815,HCPCS,,,facility,both,,,,7055,5291.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pet Whole Body,9513918,CDM,404,RC,78816,HCPCS,,,facility,both,,,,7512,5634,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Rx Oral Admin,9513921,CDM,342,RC,79005,HCPCS,,,facility,both,,,,1375,1031.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Rx Iv Admin,9513924,CDM,342,RC,79101,HCPCS,,,facility,both,,,,1455,1091.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Duplex Arterial Carotid Complete Bilateral,9513969,CDM,921,RC,93880,HCPCS,,,facility,both,,,,717,537.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Duplex Arterial Carotid Complete Bilateral,9513969,CDM,921,RC,93880,HCPCS,,,facility,both,,,,900,675,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Duplex Arterial Carotid Unilateral Or Limited,9513972,CDM,921,RC,93882,HCPCS,,,facility,both,,,,480,360,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Duplex Arterial Carotid Unilateral Or Limited,9513972,CDM,921,RC,93882,HCPCS,,,facility,both,,,,480,360,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Noninvasv Extrem 1-2 Level Bilat,9513987,CDM,921,RC,93922,HCPCS,,,facility,both,,,,375,281.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Non-Invasive Physiologic Study Extremity 3 Or More Levels,9513990,CDM,921,RC,93923,HCPCS,,,facility,both,,,,403,302.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Non-Invasive Physiologic Study Extremity 3 Or More Levels,9513990,CDM,921,RC,93923,HCPCS,,,facility,both,,,,550,412.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Noninvasive Physiologic Std Lxtr Art Compl Bi,9513993,CDM,921,RC,93924,HCPCS,,,facility,both,,,,354,265.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Noninvasive Physiologic Std Lxtr Art Compl Bi,9513993,CDM,921,RC,93924,HCPCS,,,facility,both,,,,1104,828,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dup-Scan Lxtr Art/Artl Bypass Grafts Compl Bi Study,9513996,CDM,921,RC,93925,HCPCS,,,facility,both,,,,919,689.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dup-Scan Lxtr Art/Artl Bypass Grafts Compl Bi Study,9513996,CDM,921,RC,93925,HCPCS,,,facility,both,,,,775,581.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Dup-Scan Lxtr Art/Artl Bypass Grafts Uni/Lmtd Study,9513999,CDM,921,RC,93926,HCPCS,,,facility,both,,,,798,598.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dup-Scan Lxtr Art/Artl Bypass Grafts Uni/Lmtd Study,9513999,CDM,921,RC,93926,HCPCS,,,facility,both,,,,587,440.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Dup-Scan Uxtr Art/Artl Bypass Grafts Compl Bi Study,9514002,CDM,921,RC,93930,HCPCS,,,facility,both,,,,788,591,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dup-Scan Uxtr Art/Artl Bypass Grafts Compl Bi Study,9514002,CDM,921,RC,93930,HCPCS,,,facility,both,,,,788,591,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Dup-Scan Uxtr Art/Artl Bypass Uni/Lmtd Study,9514005,CDM,921,RC,93931,HCPCS,,,facility,both,,,,785,588.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dup-Scan Uxtr Art/Artl Bypass Uni/Lmtd Study,9514005,CDM,921,RC,93931,HCPCS,,,facility,both,,,,469,351.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Dup-Scan Xtr Veins Complete Bilateral Study - 93970,9514008,CDM,921,RC,93970,HCPCS,,,facility,both,,,,1197,897.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dup-Scan Xtr Veins Complete Bilateral Study - 93970,9514008,CDM,921,RC,93970,HCPCS,,,facility,both,,,,776,582,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Dup-Scan Xtr Veins Unilateral/Limited Study - 93971,9514011,CDM,921,RC,93971,HCPCS,,,facility,both,,,,882,661.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Dup-Scan Xtr Veins Unilateral/Limited Study - 93971,9514011,CDM,921,RC,93971,HCPCS,,,facility,both,,,,481,360.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Duplex Arterial/Venous Renal, Complete",9514014,CDM,921,RC,93975,HCPCS,,,facility,both,,,,1056,792,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Duplex Abd/Pel Vasc Study Ltd,9514017,CDM,921,RC,93976,HCPCS,,,facility,both,,,,780,585,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Duplex Large Vessel(S) Complete,9514020,CDM,921,RC,93978,HCPCS,,,facility,both,,,,924,693,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Duplex Large Vessel(S) Complete,9514020,CDM,921,RC,93978,HCPCS,,,facility,both,,,,624,468,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Duplex Large Vessel(S) Ltd,9514023,CDM,921,RC,93979,HCPCS,,,facility,both,,,,556,417,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Duplex Scan Hemodialysis Access,9514029,CDM,921,RC,93990,HCPCS,,,facility,both,,,,571,428.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Office/Outpatient Established Mod Mdm, If Using Time, 30 Minutes Or More",9514060,CDM,510,RC,99214,HCPCS,,,facility,both,,,,325,243.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Office/Outpatient Established Mod Mdm, If Using Time, 30 Minutes Or More",9514060,CDM,510,RC,99214,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Biopsy/Excision Lymph Node(S)  Needle Superficial,9514062,CDM,361,RC,38505,HCPCS,,,facility,both,,,,1957,1467.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mech Rem Pericath Obstr Material,9514063,CDM,361,RC,36595,HCPCS,,,facility,both,,,,3934,2950.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Reposition Feeding Tube,9514065,CDM,361,RC,43761,HCPCS,,,facility,both,,,,1704,1278,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incision/Drainage Hematoma/Seroma Or Fluid Collection,9514066,CDM,361,RC,10140,HCPCS,,,facility,both,,,,2875,2156.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incision/Drainage Hematoma/Seroma Or Fluid Collection,9514066,CDM,361,RC,10140,HCPCS,,,facility,both,,,,6596,4947,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Incision/Drainage Hematoma/Seroma Or Fluid Collection,9514066,CDM,361,RC,10140,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Puncture Aspiration Of Abscess,Hematoma, Bulla Or Cyst",9514073,CDM,361,RC,10160,HCPCS,,,facility,both,,,,632,474,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Puncture Aspiration Of Abscess,Hematoma, Bulla Or Cyst",9514073,CDM,361,RC,10160,HCPCS,,,facility,both,,,,550,412.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Puncture Aspiration Of Abscess,Hematoma, Bulla Or Cyst",9514073,CDM,361,RC,10160,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Puncture Aspiration Cyst Breast,9514074,CDM,361,RC,19000,HCPCS,,,facility,both,,,,1615,1211.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Puncture Aspiration Breast Each Additional Cyst,9514075,CDM,361,RC,19001,HCPCS,,,facility,both,,,,736,552,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Bone Trocar/Needle Superficial,9514083,CDM,361,RC,20220,HCPCS,,,facility,both,,,,2109,1581.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Bone Trocar/Needle Deep,9514084,CDM,361,RC,20225,HCPCS,,,facility,both,,,,3066,2299.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Sinus Tract Diagnostic,9514085,CDM,361,RC,20501,HCPCS,,,facility,both,,,,774,580.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrohcentesis Major Joint Or Bursa W/O Us Guidanhce,9514086,CDM,361,RC,20610,HCPCS,,,facility,both,,,,608,456,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrohcentesis Major Joint Or Bursa W/O Us Guidanhce,9514086,CDM,361,RC,20610,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Arthrohcentesis Major Joint Or Bursa W/O Us Guidanhce,9514086_50,CDM,361,RC,20610,HCPCS,,,facility,both,,,50,912,684,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Arthrohcentesis Major Joint Or Bursa W/O Us Guidanhce,9514086_50,CDM,361,RC,20610,HCPCS,,,facility,both,,,50,411,308.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Biopsy Soft Tissue Nehck/Hchest,9514087,CDM,361,RC,21550,HCPCS,,,facility,both,,,,3803,2852.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Shoulder Arthrography/ Ct/Mri Arthg,9514091,CDM,361,RC,23350,HCPCS,,,facility,both,,,,450,337.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Procedure For Elbow Arthrography,9514092,CDM,361,RC,24220,HCPCS,,,facility,both,,,,333,249.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Wrist Arthrography,9514093,CDM,361,RC,25246,HCPCS,,,facility,both,,,,479,359.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Hip Arthrography W/O Anesthesia,9514094,CDM,361,RC,27093,HCPCS,,,facility,both,,,,563,422.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Ankle Arthrography,9514096,CDM,361,RC,27648,HCPCS,,,facility,both,,,,343,257.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Pleura Percutaneous Needle,9514098,CDM,361,RC,32400,HCPCS,,,facility,both,,,,2928,2196,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insertion Indwelling Tunneled Pleural Catheter W Cuff,9514102,CDM,361,RC,32550,HCPCS,,,facility,both,,,,6463,4847.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tube Thoracostomy, Inhcludes Connehction To Drainage System, When Performed, Open (Separate Proce",9514103,CDM,361,RC,32551,HCPCS,,,facility,both,,,,1495,1121.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Tube Thoracostomy, Inhcludes Connehction To Drainage System, When Performed, Open (Separate Proce",9514103,CDM,361,RC,32551,HCPCS,,,facility,both,,,,1495,1121.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Injehction, Venography",9514111,CDM,361,RC,36005,HCPCS,,,facility,both,,,,929,696.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Intro Catheter Superior/Inferior Vena Cava,9514112,CDM,361,RC,36010,HCPCS,,,facility,both,,,,993,744.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Slctv Cath Plmt Ven Sys 1St Order Branch,9514113,CDM,361,RC,36011,HCPCS,,,facility,both,,,,1324,993,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Slctv Cath Plmt Ven Sys 2Nd Order/> Slctv Branc,9514114,CDM,361,RC,36012,HCPCS,,,facility,both,,,,1317,987.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Slctv Catheter Plmt Left/Right Pulmonary Artery,9514115,CDM,361,RC,36014,HCPCS,,,facility,both,,,,1644,1233,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Introduction Needle Or Intracatheter Upper Or Lower Extremity Artery,9514117,CDM,361,RC,36140,HCPCS,,,facility,both,,,,650,487.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Place Cath Aorta,9514119,CDM,361,RC,36200,HCPCS,,,facility,both,,,,2069,1551.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Place Cath Selective Art Neck,9514120,CDM,361,RC,36215,HCPCS,,,facility,both,,,,2655,1991.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Place Cath Subselect Art Neck,9514121,CDM,361,RC,36216,HCPCS,,,facility,both,,,,2549,1911.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Place Cath Subsubselect Art Neck,9514122,CDM,361,RC,36217,HCPCS,,,facility,both,,,,2927,2195.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Place Cath Addn Subselec Art Neck,9514123,CDM,361,RC,36218,HCPCS,,,facility,both,,,,1500,1125,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Place Cath Select Art Abd/Pel,9514124,CDM,361,RC,36245,HCPCS,,,facility,both,,,,2691,2018.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Place Cath Subselect Art Abd/Pel,9514125,CDM,361,RC,36246,HCPCS,,,facility,both,,,,2850,2137.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Place Cath Subsubselect Art Abd/Pel,9514126,CDM,361,RC,36247,HCPCS,,,facility,both,,,,3840,2880,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Place Cath Addn Subsel Art Abd/Pel,9514127,CDM,361,RC,36248,HCPCS,,,facility,both,,,,2354,1765.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prq Portal Vein Catheterization Any Method,9514129,CDM,361,RC,36481,HCPCS,,,facility,both,,,,2431,1823.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Insert Non-Tunneled Central Venous Cath, Less Than 5 Years Of Age",9514131,CDM,361,RC,36555,HCPCS,,,facility,both,,,,3465,2598.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insert Non-Tunneled Central Venous Cath Age 5 Years Or Older,9514132,CDM,361,RC,36556,HCPCS,,,facility,both,,,,3444,2583,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insert Tunneled Cvc W/O Subq Port/Pmp Age 5 Years Or Older,9514134,CDM,361,RC,36558,HCPCS,,,facility,both,,,,6469,4851.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insert Tunneled Ctr Vad W/Subq Port Age 5 Years Or Older,9514136,CDM,361,RC,36561,HCPCS,,,facility,both,,,,7938,5953.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Insertion Periph Central Ven Cath, W/O Sub Port Or Pump, W/O Imaging Guidance, < 5 Yrs Of Age",9514137,CDM,361,RC,36568,HCPCS,,,facility,both,,,,2823,2117.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Insertion Periph Central Ven Cath, W/O Sub Port Or Pump, W/O Imaging Guidance, < 5 Yrs Of Age",9514137,CDM,361,RC,36568,HCPCS,,,facility,both,,,,2823,2117.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Insertion Peripherally Central Venous Access,W/Sub Port, 5Yrs&Older",9514140,CDM,361,RC,36571,HCPCS,,,facility,both,,,,7448,5586,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Replace Non-Tunneled Cv Catheter, W/O Port Or Pump, Same Venous Access",9514141,CDM,361,RC,36580,HCPCS,,,facility,both,,,,2416,1812,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Replace Tunneled Cv Catheter, W/O Port Or Pump, Same Venous Access",9514142,CDM,361,RC,36581,HCPCS,,,facility,both,,,,5721,4290.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Replace Tunneled Cv Catheter, With Port, Same Venous Access",9514143,CDM,361,RC,36582,HCPCS,,,facility,both,,,,4921,3690.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repl Cmpl Picc Wo Subq Port/Pump With Imaging,9514144,CDM,361,RC,36584,HCPCS,,,facility,both,,,,2784,2088,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Tunneled Cvc W/O Sq Port/Pump,9514146,CDM,361,RC,36589,HCPCS,,,facility,both,,,,1941,1455.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Tunneled Cvc W/O Sq Port/Pump,9514146,CDM,361,RC,36589,HCPCS,,,facility,both,,,,1688,1266,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Removal Tunneled Cvc W/O Sq Port/Pump,9514146,CDM,361,RC,36589,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Remv Tunnld Cvad W/Subq Port/Pump,9514147,CDM,361,RC,36590,HCPCS,,,facility,both,,,,2931,2198.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Remv Tunnld Cvad W/Subq Port/Pump,9514147,CDM,361,RC,36590,HCPCS,,,facility,both,,,,1474,1105.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Repositioning Previously Placed Cvc Under Fluor Gdnce,9514148,CDM,361,RC,36597,HCPCS,,,facility,both,,,,2378,1783.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cntrst Njx Rad Eval Ctr Vad Fluor Img&Reprt,9514149,CDM,361,RC,36598,HCPCS,,,facility,both,,,,590,442.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insertion Transvns Intrahepatc Portosysic Shunt,9514150,CDM,361,RC,37182,HCPCS,,,facility,both,,,,9773,7329.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Revision Transvns Intrhptc Portosystemic Shnt (Tips),9514151,CDM,361,RC,37183,HCPCS,,,facility,both,,,,11104,8328,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prim Prq Trluml Mchnl Thrmbc 1St Vsl,9514152,CDM,361,RC,37184,HCPCS,,,facility,both,,,,11244,8433,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prim Prq Trluml Mchnl Thrmbc Sbsq Vsl,9514153,CDM,361,RC,37185,HCPCS,,,facility,both,,,,2298,1723.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Prq Trluml Mchnl Thrmbc Vein,9514155,CDM,361,RC,37187,HCPCS,,,facility,both,,,,11139,8354.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Transcatheter Biopsy,9514157,CDM,361,RC,37200,HCPCS,,,facility,both,,,,4626,3469.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Trnscth Plcmnt Intravasc Stent(S), Cca, Opn Or Perc, Incl Angioplsty, If Done, & Rad S&I; W/Dep",9514165,CDM,361,RC,37215,HCPCS,,,facility,both,,,,23292,17469,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Radioactive Tracer For Id Of Sentinel Node,9514169,CDM,361,RC,38792,HCPCS,,,facility,both,,,,695,521.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Salivary Gland Needle,9514170,CDM,361,RC,42400,HCPCS,,,facility,both,,,,2513,1884.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,9514173,CDM,361,RC,43752,HCPCS,,,facility,both,,,,654,490.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Introduction Long Gi Tube Separate Procedure,9514176,CDM,361,RC,44500,HCPCS,,,facility,both,,,,934,700.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Liver Needle Percutaneous,9514178,CDM,361,RC,47000,HCPCS,,,facility,both,,,,2501,1875.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ablation One Or More Liver Tumor Perc Rf,9514180,CDM,361,RC,47382,HCPCS,,,facility,both,,,,8700,6525,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cholecystostomy Percutaneous,9514181,CDM,361,RC,47490,HCPCS,,,facility,both,,,,7274,5455.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Pancrea Percutaneous Needle,9514189,CDM,361,RC,48102,HCPCS,,,facility,both,,,,4311,3233.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Percut Needle Biopsy, Abdominal Mass",9514196,CDM,361,RC,49180,HCPCS,,,facility,both,,,,1718,1288.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Drainage Catheter Exchange,9514197,CDM,361,RC,49423,HCPCS,,,facility,both,,,,3251,2438.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Contrast Inject In Place Catheter,9514198,CDM,361,RC,49424,HCPCS,,,facility,both,,,,483,362.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insert G-Tube Perc Fluoro Incl Contrast Inj,9514199,CDM,361,RC,49440,HCPCS,,,facility,both,,,,3552,2664,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insert Duod/Jejun Tube Percfluoro Incl Cntrst Inj,9514200,CDM,361,RC,49441,HCPCS,,,facility,both,,,,2205,1653.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Convert G Tube Thc Gj Tube Perhc W/ Fluoro Incl Contrast Inj,9514202,CDM,361,RC,49446,HCPCS,,,facility,both,,,,2842,2131.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Replace Gastrostomy/Cecostomy Tube Percutaneous,9514203,CDM,361,RC,49450,HCPCS,,,facility,both,,,,1464,1098,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Replace Duodenostomy/Jejunostomy Tube Perq,9514204,CDM,361,RC,49451,HCPCS,,,facility,both,,,,1794,1345.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repl Gastro Jejun Tube Perc Fluoro Incl Cntrst Inj,9514205,CDM,361,RC,49452,HCPCS,,,facility,both,,,,1702,1276.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mech Rem Obstr Mat Frm Tube Any Meth W/Fluor Incl Cont Inj,9514206,CDM,361,RC,49460,HCPCS,,,facility,both,,,,1296,972,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Contrast Injection Perc Radiologic Eval Gi Tube,9514207,CDM,361,RC,49465,HCPCS,,,facility,both,,,,291,218.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Of Kidney Percutaneous,9514209,CDM,361,RC,50200,HCPCS,,,facility,both,,,,2139,1604.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Indwelling Ureteral Stent Prq,9514211,CDM,361,RC,50384,HCPCS,,,facility,both,,,,2921,2190.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rmvl & Rplcmt Xtrnl Accessible Nephrourtrl Cath,9514214,CDM,361,RC,50387,HCPCS,,,facility,both,,,,2584,1938,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rmvl & Rplcmt Xtrnl Accessible Nephrourtrl Cath,9514214,CDM,361,RC,50387,HCPCS,,,facility,both,,,,2247,1685.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Rmvl Nfros Tube Req Fluoro Guidance,9514215,CDM,361,RC,50389,HCPCS,,,facility,both,,,,1548,1161,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspir &/Njx Renal Cyst/Pelvis Needle Prq,9514216,CDM,361,RC,50390,HCPCS,,,facility,both,,,,2047,1535.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ir-Perc Rf Ablation Renal Tumor(S) Uni,9514222,CDM,361,RC,50592,HCPCS,,,facility,both,,,,8709,6531.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ablation Renal Tumor Unilateral Perq Cryotherapy,9514223,CDM,361,RC,50593,HCPCS,,,facility,both,,,,12667,9500.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Inj Px Ureterography/Ureteropylography Cath,9514224,CDM,361,RC,50684,HCPCS,,,facility,both,,,,2684,2013,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Chng Urtrost Tube/Xtrnlly Accessible Stent Ileal,9514225,CDM,361,RC,50688,HCPCS,,,facility,both,,,,3156,2367,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Inj Visualization Ileal Conduit&/Ureteropyelog,9514226,CDM,361,RC,50690,HCPCS,,,facility,both,,,,1937,1452.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspiration Bladder Needle,9514227,CDM,361,RC,51100,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspiration Bladder Needle,9514227,CDM,361,RC,51100,HCPCS,,,facility,both,,,,417,312.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Aspiration Bladder Insert Suprapubic Catheter,9514229,CDM,361,RC,51102,HCPCS,,,facility,both,,,,7544,5658,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection For Bladder X-Ray,9514230,CDM,361,RC,51600,HCPCS,,,facility,both,,,,533,399.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cath & Saline/Contrast Sonohyster/Hysterosalpi,9514233,CDM,361,RC,58340,HCPCS,,,facility,both,,,,282,211.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Amniocentesis Diagnostic,9514235,CDM,361,RC,59000,HCPCS,,,facility,both,,,,1012,759,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Thyroid Percutaneous Core Needle,9514236,CDM,361,RC,60100,HCPCS,,,facility,both,,,,1041,780.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Aspiration And/Or Injection Thyroid Cyst,9514237,CDM,361,RC,60300,HCPCS,,,facility,both,,,,883,662.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Puncture Shunt Tube/Reservoir Aspiration/Inj Px,9514239,CDM,361,RC,61070,HCPCS,,,facility,both,,,,1729,1296.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Percut Cath Occlusn Cns Lesn,9514242,CDM,361,RC,61624,HCPCS,,,facility,both,,,,23461,17595.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Percut Cath Occlusn Non Cns Lesn,9514243,CDM,361,RC,61626,HCPCS,,,facility,both,,,,17183,12887.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Spinal Puncture, Lumbar, Diagnostic",9514249,CDM,361,RC,62270,HCPCS,,,facility,both,,,,1130,847.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Inj Proc For Myelography And/Or Computed Tomography, Lumbar (Other Than C1-C2 And Posterior Fossa",9514250,CDM,361,RC,62284,HCPCS,,,facility,both,,,,709,531.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Percutaneous Lumbar Diskectomy,9514251,CDM,361,RC,62287,HCPCS,,,facility,both,,,,8775,6581.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ablation Therapy For Bone Tumor Rfi,9514260,CDM,361,RC,20982,HCPCS,,,facility,both,,,,12372,9279,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Biopsy Muscle Percutaneous Needle,9514262,CDM,361,RC,20206,HCPCS,,,facility,both,,,,1577,1182.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrocentesis Inter Joint Or Bursa W/O Us Guidance,9514263,CDM,361,RC,20605,HCPCS,,,facility,both,,,,599,449.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrocentesis Inter Joint Or Bursa W/O Us Guidance,9514263,CDM,361,RC,20605,HCPCS,,,facility,both,,,,599,449.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Arthrocentesis Inter Joint Or Bursa W/O Us Guidance,9514263,CDM,361,RC,20605,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Arthrocentesis Inter Joint Or Bursa W/O Us Guidance,9514263_50,CDM,361,RC,20605,HCPCS,,,facility,both,,,50,899,674.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Arthrocentesis Inter Joint Or Bursa W/O Us Guidance,9514263_50,CDM,361,RC,20605,HCPCS,,,facility,both,,,50,899,674.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Arthrocentesis Inter Joint Or Bursa W/O Us Guidance,9514263_50,CDM,361,RC,20605,HCPCS,,,facility,both,,,50,411,308.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Thrombin Injection For Pseudoaneurysm,9514270,CDM,361,RC,36002,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Thrombin Injection For Pseudoaneurysm,9514270,CDM,361,RC,36002,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Slctv Cath Plmt Segmental/Subsegmental Pulm Art,9514271,CDM,361,RC,36015,HCPCS,,,facility,both,,,,1319,989.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Epidural Blood/Clot Patch,9514273,CDM,361,RC,62273,HCPCS,,,facility,both,,,,1932,1449,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Epidural Blood/Clot Patch,9514273,CDM,361,RC,62273,HCPCS,,,facility,both,,,,1932,1449,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Injection(S) Anesthetic Agent(S) And Or Steroid,Trigemincal Nerve Each Branch",9514274,CDM,361,RC,64400,HCPCS,,,facility,both,,,,877,657.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Injection(S) Anesthetic Agent(S) And Or Steroid,Trigemincal Nerve Each Branch",9514274,CDM,361,RC,64400,HCPCS,,,facility,both,,,,1009,756.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Injection(S), Anesthetic Agent(S) And/Or Steroid, Other Peripheral Nerve Or Branch",9514275,CDM,361,RC,64450,HCPCS,,,facility,both,,,,1325,993.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Injection(S), Anesthetic Agent(S) And/Or Steroid, Other Peripheral Nerve Or Branch",9514275,CDM,361,RC,64450,HCPCS,,,facility,both,,,,1325,993.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Chemo Admn Cns Req Spinal Puncture,9514276,CDM,331,RC,96450,HCPCS,,,facility,both,,,,1360,1020,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Chemo Admin Intra Arterial Push,9514277,CDM,331,RC,96420,HCPCS,,,facility,both,,,,428,321,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O Us,9514278,CDM,361,RC,20600,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O Us,9514278,CDM,361,RC,20600,HCPCS,,,facility,both,,,,403,302.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O Us,9514278,CDM,361,RC,20600,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O Us,9514278_50,CDM,361,RC,20600,HCPCS,,,facility,both,,,50,605,453.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O Us,9514278_50,CDM,361,RC,20600,HCPCS,,,facility,both,,,50,411,308.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O Us,9514278_50,CDM,361,RC,20600,HCPCS,,,facility,both,,,50,579,434.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Stent Placement Vertebral 1St Vsl,9514286,CDM,361,RC,0075T,HCPCS,,,facility,both,,,,7943,5957.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mra Chest W/ Or W/O Contrast,9514322,CDM,618,RC,71555,HCPCS,,,facility,both,,,,2343,1757.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra Without Contrast & With Contrast, Pelvis",9514340,CDM,618,RC,72198,HCPCS,,,facility,both,,,,2343,1757.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra Without Contrast & With Contrast, Lower Extremity",9514352,CDM,618,RC,73725,HCPCS,,,facility,both,,,,2271,1703.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra With Contrast, Abdomen",9514355,CDM,618,RC,74185,HCPCS,,,facility,both,,,,2343,1757.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra Without Contrast, Abdomen",9514358,CDM,618,RC,74185,HCPCS,,,facility,both,,,,2343,1757.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mra Abdomen W/ Or W/O Contrast Material,9514361,CDM,618,RC,74185,HCPCS,,,facility,both,,,,2343,1757.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Tomography Single Plane,9514366,CDM,320,RC,76100,HCPCS,,,facility,both,,,,431,323.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Embolization Transcatheter,9514476,CDM,320,RC,75894,HCPCS,,,facility,both,,,,3951,2963.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angio Cath Infusion Follow Up,9514477,CDM,323,RC,75898,HCPCS,,,facility,both,,,,2004,1503,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Remove Cva Device Obstruct,9514478,CDM,320,RC,75901,HCPCS,,,facility,both,,,,943,707.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Debridement,Open Wound,Per Session,Total Surface First 20 Sq Cm",9514484,CDM,761,RC,97597,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Debridement,Open Wound,Per Session,Total Surface First 20 Sq Cm",9514484,CDM,761,RC,97597,HCPCS,,,facility,both,,,,567,425.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Debridement,Open Wound,Per Session,Total Surface First 20 Sq Cm",9514484,CDM,761,RC,97597,HCPCS,,,facility,both,,,,493,369.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Debridement,Open Wound,Per Session,Total Surface Ea Addtl 20 Sq Cm",9514485,CDM,761,RC,97598,HCPCS,,,facility,both,,,,317,237.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Debridement,Open Wound,Per Session,Total Surface Ea Addtl 20 Sq Cm",9514485,CDM,761,RC,97598,HCPCS,,,facility,both,,,,317,237.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Neg Press Wound Thrpy, W/Dme,Topicl Applc,Wound Assessmt,Per Session, < Or Eq To 50 Sq Cm",9514487,CDM,761,RC,97605,HCPCS,,,facility,both,,,,402,301.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Neg Press Wound Thrpy, W/Dme,Topicl Applc,Wound Assessmt,Per Session, < Or Eq To 50 Sq Cm",9514487,CDM,761,RC,97605,HCPCS,,,facility,both,,,,350,262.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Neg Press Wound Thrpy, W/Dme,Topicl Applc,Wound Assessmt,Per Session, > 50 Sq Cm",9514488,CDM,761,RC,97606,HCPCS,,,facility,both,,,,456,342,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Neg Press Wound Thrpy, W/Dme,Topicl Applc,Wound Assessmt,Per Session, > 50 Sq Cm",9514488,CDM,761,RC,97606,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Application Of Multi-Layer Compression System; Leg (Below Knee), Including Ankle And Foot",9514506,CDM,761,RC,29581,HCPCS,,,facility,both,,,,448,336,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff,9514510,CDM,361,RC,32552,HCPCS,,,facility,both,,,,1180,885,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Rdtx Perc Plcmnt Rd Tx Guid Dev, Abd/Pel",9514514,CDM,361,RC,49411,HCPCS,,,facility,both,,,,3749,2811.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Percutaneous Balloon Valvuloplasty,Aortic Valve",9514518,CDM,481,RC,92986,HCPCS,,,facility,both,,,,13330,9997.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cardiopulmonary Resuscitation,9514519,CDM,480,RC,92950,HCPCS,,,facility,both,,,,1380,1035,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Insert And Placement Flow Directed Catheter (Swan-Ganz)For Monitoring Purpose,9514540,CDM,481,RC,93503,HCPCS,,,facility,both,,,,3318,2488.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Intracardiac Echo During Therapeutic/Diagnostic  Intervention (Add-On),9514541,CDM,481,RC,93662,HCPCS,,,facility,both,,,,5160,3870,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Endoluminal Imaging Coronary Vessel Or Graft Using Ivus Or Oct During Diagnostic Eval,Initial Vess",9514542,CDM,481,RC,92978,HCPCS,,,facility,both,,,,6212,4659,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Endoluminal Imaging Coronary Vessel Or Graft Using Ivus Or Oct During Diagnostic Eval,Ea Addtl Ve",9514543,CDM,481,RC,92979,HCPCS,,,facility,both,,,,4311,3233.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Intravascular Doppler Velocity During Coronary Angiography;Initial Vessel,9514544,CDM,481,RC,93571,HCPCS,,,facility,both,,,,5198,3898.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Intravascular Doppler Velocity During Coronary Angiography;Ea Addtl Vessel,9514545,CDM,481,RC,93572,HCPCS,,,facility,both,,,,1702,1276.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Percutaneous Transcatheter Closure Congenital Interartrial Communication W/Implant,9514549,CDM,481,RC,93580,HCPCS,,,facility,both,,,,30289,22716.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Single/Mlt Trigger Point 1/2 Muscles,9514597,CDM,361,RC,20552,HCPCS,,,facility,both,,,,655,491.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Single/Mlt Trigger Point 1/2 Muscles,9514597,CDM,361,RC,20552,HCPCS,,,facility,both,,,,655,491.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Injection Single/Mlt Trigger Point 1/2 Muscles,9514597,CDM,361,RC,20552,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Injection Single/Mlt Trigger Point 3 Or More Muscles,9514598,CDM,361,RC,20553,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Spinal Puncture, Therapeutic, For Drainage Of Cerebrospinal Fluid (By Needle Or Catheter)",9514600,CDM,361,RC,62272,HCPCS,,,facility,both,,,,1181,885.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ct Heart No Contrast Quant Eval Coronry Calcium,9514611,CDM,350,RC,75571,HCPCS,,,facility,both,,,,233,174.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Cardiac Struct And Morph W/ Contr,9514612,CDM,350,RC,75572,HCPCS,,,facility,both,,,,1900,1425,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Cta Hrt Cornry Art/Bypass Grfts Contrst 3D Post,9514614,CDM,350,RC,75574,HCPCS,,,facility,both,,,,2300,1725,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Myocardial Spect Single Study,9514616,CDM,341,RC,78451,HCPCS,,,facility,both,,,,3636,2727,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Myocardial Spect Single Study,9514616,CDM,341,RC,78451,HCPCS,,,facility,both,,,,2938,2203.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Air/Contrast Inject Into Abdomen,9514622,CDM,361,RC,49400,HCPCS,,,facility,both,,,,483,362.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Removal Tunneled Intraperitoneal Catheter,9514624,CDM,361,RC,49422,HCPCS,,,facility,both,,,,11455,8591.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Asp Inj Nuc Pulposus Intervert Disc,9514625,CDM,361,RC,62267,HCPCS,,,facility,both,,,,1467,1100.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ct Spleen Biopsy,9514626,CDM,361,RC,38999,HCPCS,,,facility,both,,,,5883,4412.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Chest W/Contrast,9514630,CDM,610,RC,71551,HCPCS,,,facility,both,,,,3317,2487.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Compress Rep Aneurysm Or Fistulae,9514636,CDM,402,RC,76936,HCPCS,,,facility,both,,,,1298,973.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St Standard Cog Testing Per Hr,9514657,CDM,440,RC,96125,HCPCS,,,facility,both,,,,389,291.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Bladder Irrigation, Simple, Lavage And/Or Instillation",9514658,CDM,761,RC,51700,HCPCS,,,facility,both,,,,636,477,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Thrombolytic Administration,9514662,CDM,450,RC,92977,HCPCS,,,facility,both,,,,995,746.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Ot-Iontophoresis Ea 15 Min,9514665,CDM,430,RC,97033,HCPCS,,,facility,both,,,,72,54,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot-Prosthetic Training Ea 15 Min,9514680,CDM,430,RC,97761,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Bone Marrow Biopsy(Ies),9514686,CDM,361,RC,38221,HCPCS,,,facility,both,,,,1552,1164,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Newborn Resuscitation,9514687,CDM,761,RC,99465,HCPCS,,,facility,both,,,,922,691.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fine Needle Aspiration Biopsy, Without Imaging Guidance, First Lesion",9514751,CDM,361,RC,10021,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Incision & Drainage Abscess Simple/Single,9514752,CDM,361,RC,10060,HCPCS,,,facility,both,,,,540,405,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Incision & Drainage Abscess Simple/Single,9514752,CDM,361,RC,10060,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Incision & Drainage Abscess Simple/Single,9514752,CDM,361,RC,10060,HCPCS,,,facility,both,,,,540,405,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Inj Procedure For Sacroiliac Joint; Arthrography,9514757,CDM,361,RC,27096,HCPCS,,,facility,both,,,,924,693,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Repair Cva Device W Port/Pump,9514761,CDM,361,RC,36576,HCPCS,,,facility,both,,,,2906,2179.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc I&D Ischiorectal And/Or Perirectal Abscess Spx,9514769,CDM,361,RC,46040,HCPCS,,,facility,both,,,,3336,2502,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc I&D Perianal Abscess Superficial,9514770,CDM,361,RC,46050,HCPCS,,,facility,both,,,,832,624,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc I&D Perianal Abscess Superficial,9514770,CDM,361,RC,46050,HCPCS,,,facility,both,,,,2010,1507.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc I&D Perianal Abscess Superficial,9514770,CDM,361,RC,46050,HCPCS,,,facility,both,,,,2010,1507.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Injection(S), Anesthetic Agent And/Or Steroid; Transforaminal Epidural, With Imaging Guidance (Fl",9514780,CDM,361,RC,64479,HCPCS,,,facility,both,,,,3316,2487,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Injection Anes Lmbr/Thrc Paravertbrl Sympathetic,9514784,CDM,361,RC,64520,HCPCS,,,facility,both,,,,3317,2487.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Injection Anes Lmbr/Thrc Paravertbrl Sympathetic,9514784,CDM,361,RC,64520,HCPCS,,,facility,both,,,,881,660.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Celiac Plexus Block,9514785,CDM,361,RC,64530,HCPCS,,,facility,both,,,,2036,1527,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Peritoneogram,9514792,CDM,320,RC,74190,HCPCS,,,facility,both,,,,634,475.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Perc Trans Porto W Hemo Eval,9514796,CDM,320,RC,75885,HCPCS,,,facility,both,,,,5426,4069.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Perc Trans Porto Wo Hemo Eval,9514797,CDM,320,RC,75887,HCPCS,,,facility,both,,,,1868,1401,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Hepatic Veno Wo Hemo Eval,9514798,CDM,320,RC,75891,HCPCS,,,facility,both,,,,5022,3766.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Liver/Spleen-Vascular,9514804,CDM,341,RC,78216,HCPCS,,,facility,both,,,,2592,1944,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt Chest Physio Init 4+ Posn,9514819,CDM,410,RC,94667,HCPCS,,,facility,both,,,,338,253.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ext Chest Wall Osc-Vest Init,9514820,CDM,410,RC,94669,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ext Chest Wall Osc-Vest Subs,9514821,CDM,410,RC,94669,HCPCS,,,facility,both,,,,271,203.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt Chest Physio 4+ Posn,9514822,CDM,410,RC,94668,HCPCS,,,facility,both,,,,253,189.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Svn Tx W Mech Vent,9514831,CDM,410,RC,94640,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-Ab Administration Svn Tx,9514836,CDM,410,RC,94640,HCPCS,,,facility,both,,,,251,188.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-In/Exsuffolator Initial,9514839,CDM,410,RC,94640,HCPCS,,,facility,both,,,,197,147.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Rt-In/Exsuffolator Initial,9514839,CDM,410,RC,94640,HCPCS,,,facility,both,,,,251,188.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Rt-In/Exsuffolator Subsq,9514840,CDM,410,RC,94640,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C  Pharmacologic Agent Admin Inc Assessing Hemodynamic Measurements Before,During, After",9514876,CDM,481,RC,93463,HCPCS,,,facility,both,,,,780,585,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Transluminal Peripheral Atherectomy,Open Or Percutaneous,Iliac Artery Ea Vessel",9514881,CDM,361,RC,0238T,HCPCS,,,facility,both,,,,24608,18456,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Right Heart Catheterization Inc Measurements,9514882,CDM,481,RC,93451,HCPCS,,,facility,both,,,,9674,7255.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Left Heart Catheterization Inc Intraprocedural Injection Lt Ventriculography,9514883,CDM,481,RC,93452,HCPCS,,,facility,both,,,,10303,7727.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Catheter Placement Coronary Artery For Coronary Angiography,Inc S&I",9514885,CDM,481,RC,93454,HCPCS,,,facility,both,,,,11797,8847.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Catheter Placement Coronary Artery For Coronary Angiography,W/Catheter Placement In Bypass Graft A",9514886,CDM,481,RC,93455,HCPCS,,,facility,both,,,,11797,8847.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Catheter Placement Coronary Artery For Coronary Angiography, W/Rt Heart Cath",9514887,CDM,481,RC,93456,HCPCS,,,facility,both,,,,17011,12758.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Catheter Placement Coronary Artery For Coronary Angiography,W/Catheter Placement In Bypass Graft A",9514888,CDM,481,RC,93457,HCPCS,,,facility,both,,,,18912,14184,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Catheter Placement Coronary Artery W/Lt Heart Cath Inc Lt Ventriculography,9514889,CDM,481,RC,93458,HCPCS,,,facility,both,,,,17509,13131.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Catheter Placement Coronary Artery W/Lt Heart Cath Inc Lt Ventriculography In Bypass Graft,9514890,CDM,481,RC,93459,HCPCS,,,facility,both,,,,18770,14077.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Cath Placement Coronary Artery For Coronary Angio,W/Rt And Lt Heart Cath Inc Lt Ventriculography",9514891,CDM,481,RC,93460,HCPCS,,,facility,both,,,,17758,13318.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Cath Placement Coronary Artery For Coronary Angio,W/Rt And Lt Heart Cath Inc Lt Ventriculography,B",9514892,CDM,481,RC,93461,HCPCS,,,facility,both,,,,16517,12387.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Lt Heart Cath By Transseptal Puncture Intact Septum Or Transapical Puncture (Add-On),9514893,CDM,481,RC,93462,HCPCS,,,facility,both,,,,11399,8549.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Congenital Cardiac Anomalies, Supravalvular Aortography (Add-On)",9514897,CDM,481,RC,93567,HCPCS,,,facility,both,,,,889,666.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Abd & Pelvis W/O Contrast,9514900,CDM,352,RC,74176,HCPCS,,,facility,both,,,,2350,1762.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Abdomen&Pelvis W/Contrast,9514901,CDM,352,RC,74177,HCPCS,,,facility,both,,,,3050,2287.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ct Abd&Pelv 1+ Section/Regns,9514902,CDM,350,RC,74178,HCPCS,,,facility,both,,,,3500,2625,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Intub/Asp Tx,9514910,CDM,750,RC,43753,HCPCS,,,facility,both,,,,483,362.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous, Iliac Artery, Unilateral,Initial Vessel W/Tra",9514915,CDM,361,RC,37220,HCPCS,,,facility,both,,,,13041,9780.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous, Iliac Artery, Unilateral,Initial Vessel W/Tra",9514916,CDM,361,RC,37221,HCPCS,,,facility,both,,,,21230,15922.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous, Iliac Artery, Unilateral,Initial Vessel W/Tra",9514918,CDM,361,RC,37223,HCPCS,,,facility,both,,,,10349,7761.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous,Femoral, Popliteal Artery,Unilateral W/Translu",9514919,CDM,361,RC,37224,HCPCS,,,facility,both,,,,12075,9056.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous,Femoral, Popliteal Artery,Unilateral W/Atherec",9514920,CDM,361,RC,37225,HCPCS,,,facility,both,,,,22381,16785.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous,Femoral, Popliteal Artery,Unilateral W/Translu",9514921,CDM,361,RC,37226,HCPCS,,,facility,both,,,,16808,12606,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous,Femoral, Popliteal Artery,Unilateral W/Translu",9514922,CDM,361,RC,37227,HCPCS,,,facility,both,,,,29382,22036.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous,Tibial,Peroneal Artery,Unilateral,Initial Vess",9514923,CDM,361,RC,37228,HCPCS,,,facility,both,,,,12132,9099,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous,Tibial,Peroneal Artery,Unilateral,Initial Vess",9514924,CDM,361,RC,37229,HCPCS,,,facility,both,,,,18412,13809,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous,Tibial,Peroneal Artery,Unilateral,Initial Vess",9514925,CDM,361,RC,37230,HCPCS,,,facility,both,,,,20118,15088.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Endovascular,Open Or Percutaneous,Tibial/Peroneal Artery,Unilateral,Ea Addlt Ves",9514927,CDM,361,RC,37232,HCPCS,,,facility,both,,,,11307,8480.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir-Venogram Sinus/Jugular,9514943,CDM,323,RC,75860,HCPCS,,,facility,both,,,,3148,2361,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Neurostim Analyze, No Program",9514944,CDM,920,RC,95970,HCPCS,,,facility,both,,,,320,240,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Neurostim Analyze, No Program",9514944,CDM,920,RC,95970,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Us Xtr Non-Vasc Complete,9514947,CDM,402,RC,76881,HCPCS,,,facility,both,,,,792,594,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ultrasound, Limited, Joint Or Focal Evaluation Of Other Nonvascular Extremity Structure(S), Real-",9514948,CDM,402,RC,76882,HCPCS,,,facility,both,,,,505,378.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ultrasound, Limited, Joint Or Focal Evaluation Of Other Nonvascular Extremity Structure(S), Real-",9514948,CDM,402,RC,76882,HCPCS,,,facility,both,,,,505,378.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Injection(S), Anesthetic Agent And/Or Steroid; Plantar Common Digital Nerve(S) (Eg, Morton's Neur",9514953,CDM,361,RC,64455,HCPCS,,,facility,both,,,,283,212.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Insert Tunnel Intraperitoneal Cath,9514957,CDM,361,RC,49418,HCPCS,,,facility,both,,,,4633,3474.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Chemodenervation Of Parotid And Submandibular Salivary Glands, Bilateral",9514959,CDM,361,RC,64611,HCPCS,,,facility,both,,,,315,236.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Remove External Ear Partial,9514960,CDM,361,RC,69110,HCPCS,,,facility,both,,,,2484,1863,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Mra Without Contrast, Chest (Excluding Myocardium)",9514971,CDM,618,RC,71555,HCPCS,,,facility,both,,,,1050,787.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra With Contrast, Chest (Excluding Myocardium)",9514972,CDM,618,RC,71555,HCPCS,,,facility,both,,,,2343,1757.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra Without Contrast & With Contrast, Chest (Excl Myocardium)",9514973,CDM,618,RC,71555,HCPCS,,,facility,both,,,,2343,1757.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra Without Contrast, Spinal Canal And Contents",9514980,CDM,618,RC,72159,HCPCS,,,facility,both,,,,1050,787.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra With Contrast, Spinal Canal And Contents",9514981,CDM,618,RC,72159,HCPCS,,,facility,both,,,,2079,1559.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mra Spine W/ Or W/O Contrast,9514982,CDM,618,RC,72159,HCPCS,,,facility,both,,,,2079,1559.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra Without Contrast, Upper Extremity",9514983,CDM,618,RC,73225,HCPCS,,,facility,both,,,,2118,1588.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra With Contrast, Upper Extremity",9514984,CDM,618,RC,73225,HCPCS,,,facility,both,,,,2678,2008.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mra Without Contrast & With Contrast, Upper Extremity",9514985,CDM,618,RC,73225,HCPCS,,,facility,both,,,,2678,2008.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Incisi Tendon Sheath Finger,9514988,CDM,361,RC,26055,HCPCS,,,facility,both,,,,2323,1742.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Incisi Tendon Sheath Finger,9514988,CDM,361,RC,26055,HCPCS,,,facility,both,,,,1460,1095,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0Cm,9514989,CDM,361,RC,11421,HCPCS,,,facility,both,,,,1155,866.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0Cm,9514989,CDM,361,RC,11421,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Incision/Removal Fb,Simple",9514990,CDM,361,RC,10120,HCPCS,,,facility,both,,,,780,585,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Incision/Removal Fb,Simple",9514990,CDM,361,RC,10120,HCPCS,,,facility,both,,,,780,585,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Incision/Removal Fb,Simple",9514990,CDM,361,RC,10120,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Inj Singl Tendon/Liga/Aponeu,9514996,CDM,361,RC,20550,HCPCS,,,facility,both,,,,552,414,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Inj Singl Tendon/Liga/Aponeu,9514996,CDM,361,RC,20550,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Inj Singl Tendon/Liga/Aponeu,9514996,CDM,361,RC,20550,HCPCS,,,facility,both,,,,552,414,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Inj Singl Tendon/Liga/Aponeu,9514996_50,CDM,361,RC,20550,HCPCS,,,facility,both,,,50,828,621,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Inj Singl Tendon/Liga/Aponeu,9514996_50,CDM,361,RC,20550,HCPCS,,,facility,both,,,50,828,621,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
Hc Inj Singl Tendon/Liga/Aponeu,9514996_50,CDM,361,RC,20550,HCPCS,,,facility,both,,,50,411,308.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
C Ecg/Monitoring And Anaylysis,9514997,CDM,731,RC,93271,HCPCS,,,facility,both,,,,342,256.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Event Monitor 24 Hr/Up To 30D,9514999,CDM,450,RC,93270,HCPCS,,,facility,both,,,,162,121.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Electronic Analysis Of Programmable, Implanted Pump For Intrathecal Or Epidural Drug Infusion, Inc",9515016,CDM,361,RC,62369,HCPCS,,,facility,both,,,,1449,1086.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Electronic Analysis Of Programmable, Implanted Pump For Intrathecal Or Epidural Drug Infusion, Inc",9515016,CDM,361,RC,62369,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Needle Electromyography, Ea Extremity, W Related Paraspinal Areas, When Perf, Done W Nerve Conduct",9515018,CDM,922,RC,95885,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ndl Electromyography Complt 5 Or More Muscles Studied,9515019,CDM,922,RC,95886,HCPCS,,,facility,both,,,,92,69,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Needle Electromyography, Non-Extremity Cranial Nerve Supplied Or Axial Muscles Done With Nerve Con",9515020,CDM,922,RC,95887,HCPCS,,,facility,both,,,,84,63,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Abdominal Paracentesis (Diagnostic Or Therapeutic); Without Imaging Guidance,9515027,CDM,761,RC,49082,HCPCS,,,facility,both,,,,1754,1315.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Removal Permanent Pacemaker Pulse Generator With Replacement Pacemaker Pulse Generator,Single Lead",9515033,CDM,480,RC,33227,HCPCS,,,facility,both,,,,20646,15484.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Removal Permanent Pacemaker Pulse Generator With Replacement Pacemaker Pulse Generator,Dual Lead S",9515034,CDM,481,RC,33228,HCPCS,,,facility,both,,,,21205,15903.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Removal Permanent Pacemaker Pulse Generator With Replacement Pacemaker Pulse Generator,Multiple Le",9515035,CDM,481,RC,33229,HCPCS,,,facility,both,,,,25347,19010.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Removal Implantable Defibrillator Pulse Generator W/Replacement Implantable Defibrillator Pulse Ge,9515038,CDM,481,RC,33262,HCPCS,,,facility,both,,,,43417,32562.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Removal Implantable Defibrillator Pulse Generator W/Replacement Implantable Defibrillator Pulse Ge,9515039,CDM,481,RC,33263,HCPCS,,,facility,both,,,,45200,33900,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Removal Implantable Defibrillator Pulse Generator W/Replacement Implantable Defibrillator Pulse Ge,9515040,CDM,481,RC,33264,HCPCS,,,facility,both,,,,47969,35976.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Carseat Airwy Tst Int 60 Min,9515041,CDM,761,RC,94780,HCPCS,,,facility,both,,,,209,156.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Carseat Airwy Tst Add 30 Min,9515042,CDM,761,RC,94781,HCPCS,,,facility,both,,,,167,125.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Plethys Lung Vol W/Wo Resist,9515046,CDM,460,RC,94726,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Plethys Lung Vol W/Wo Resist,9515046,CDM,460,RC,94726,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Gas Dil/Wash Lung Vol,9515047,CDM,460,RC,94727,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Diff Cap (Add On),9515049,CDM,460,RC,94729,HCPCS,,,facility,both,,,,395,296.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Diff Cap (Add On),9515049,CDM,460,RC,94729,HCPCS,,,facility,both,,,,90,67.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ct Angio Abd/Pelv W/&W/O Contr,9515050,CDM,352,RC,74174,HCPCS,,,facility,both,,,,3672,2754,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Hepatobil Sys Inc Gb,9515051,CDM,341,RC,78226,HCPCS,,,facility,both,,,,1984,1488,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Hepatobil Sys/Gb W/Pharm,9515052,CDM,341,RC,78227,HCPCS,,,facility,both,,,,2513,1884.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Pulm Vent/Perf Imag,9515054,CDM,341,RC,78582,HCPCS,,,facility,both,,,,2645,1983.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sel Cath Plc Imag S&I Uni,9515057,CDM,361,RC,36251,HCPCS,,,facility,both,,,,5271,3953.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Sel Cath Plc Imag S&I Bi,9515058,CDM,361,RC,36252,HCPCS,,,facility,both,,,,7582,5686.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Supsel Cath  Imag S&I Uni,9515059,CDM,361,RC,36253,HCPCS,,,facility,both,,,,5707,4280.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ir Supsel Cath  Imag S&I Bi,9515060,CDM,361,RC,36254,HCPCS,,,facility,both,,,,11455,8591.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Retrieval Ivc Filter Endovascular Approach W/Imaging S&I,9515061,CDM,361,RC,37193,HCPCS,,,facility,both,,,,8087,6065.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Electr Analysis Of Programmable Impl Pump For Intrathecal Or Epidural Drug Inf, Incld Eval Of Res",9515066,CDM,361,RC,62370,HCPCS,,,facility,both,,,,1398,1048.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Electr Analysis Of Programmable Impl Pump For Intrathecal Or Epidural Drug Inf, Incld Eval Of Res",9515066,CDM,361,RC,62370,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Injection(S), Anesthetic Agent(S) And/Or Steroid; Brachial Plexus, Including Imaging Guidance, Wh",9515067,CDM,490,RC,64415,HCPCS,,,facility,both,,,,3317,2487.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Injection(S), Anesthetic Agent(S) And/Or Steroid; Brachial Plexus, Including Imaging Guidance, Wh",9515067,CDM,490,RC,64415,HCPCS,,,facility,both,,,,881,660.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Ivc Fltr Insert W/Wo Img,S&I",9515068,CDM,361,RC,37191,HCPCS,,,facility,both,,,,11321,8490.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ultrasound Fetal Hrt Doppl F/U,9515073,CDM,483,RC,76828,HCPCS,,,facility,both,,,,547,410.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ultrasound Fetal Heart Doppler,9515074,CDM,483,RC,76827,HCPCS,,,facility,both,,,,1539,1154.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Thrombolysis, Cerebral, By Intravenous Infusion",9515080,CDM,361,RC,37195,HCPCS,,,facility,both,,,,883,662.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Cvvhd/Cvvhds Initial Set Up/Cartridge,9515084,CDM,801,RC,90935,HCPCS,,,facility,both,,,,1938,1453.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Proc-Peritoneal Dialysis/Capd,9515085,CDM,802,RC,90945,HCPCS,,,facility,both,,,,1103,827.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Proc-Peritoneal Dialysis/Ccpd,9515086,CDM,802,RC,90945,HCPCS,,,facility,both,,,,1103,827.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Doppler Color Flow Velocity,9515091,CDM,483,RC,93325,HCPCS,,,facility,both,,,,698,523.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Doppler Color Flow Velocity,9515091,CDM,483,RC,93325,HCPCS,,,facility,both,,,,698,523.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Doppler Color Flow Velocity,9515091,CDM,483,RC,93325,HCPCS,,,facility,both,,,,249,186.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ekg 12-Lead,9515092,CDM,730,RC,93005,HCPCS,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ekg 12-Lead,9515092,CDM,730,RC,93005,HCPCS,,,facility,both,,,,165,123.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Digital Analysis Electroencephalogram,9515098,CDM,740,RC,95957,HCPCS,,,facility,both,,,,901,675.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Eeg Mon Up To 41-60 Min,9515103,CDM,740,RC,95812,HCPCS,,,facility,both,,,,1139,854.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Eeg Monitoring 61-119 Min,9515104,CDM,740,RC,95813,HCPCS,,,facility,both,,,,1500,1125,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Vep Testing Chkrbrd Or Flash Cns Except Glaucoma W/I&R,9515109,CDM,740,RC,95930,HCPCS,,,facility,both,,,,1313,984.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Ssep Study Upper Limbs,9515110,CDM,740,RC,95925,HCPCS,,,facility,both,,,,1141,855.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Or-Ssep Study Lower Limbs,9515111,CDM,740,RC,95926,HCPCS,,,facility,both,,,,1141,855.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Neuro Junct Test,Ea Nerve,Any 1 Method",9515115,CDM,922,RC,95937,HCPCS,,,facility,both,,,,151,113.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Nm Thyroid  Uptake Only Single/Multiple Measurement(S),9515119,CDM,341,RC,78012,HCPCS,,,facility,both,,,,768,576,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Thyroid Imaging W/Blood Flow,9515120,CDM,341,RC,78013,HCPCS,,,facility,both,,,,768,576,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Thyroid Imaging Scan And Uptake(S),9515121,CDM,341,RC,78014,HCPCS,,,facility,both,,,,1984,1488,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pleural Drain,W/Insert Indwelling Cath W/Imaging",9515124,CDM,361,RC,32557,HCPCS,,,facility,both,,,,1938,1453.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Pleural Drain,W/Insert Indwelling Cath W/Imaging",9515124,CDM,361,RC,32557,HCPCS,,,facility,both,,,,1938,1453.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Emg Cranial Nerve,Uni",9515135,CDM,922,RC,95867,HCPCS,,,facility,both,,,,304,228,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Thoracentesis Asp Pleural Space W/Out Imaging,9515142,CDM,361,RC,32554,HCPCS,,,facility,both,,,,1254,940.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Nerve Conduction:1-2 Studies,9515144,CDM,922,RC,95907,HCPCS,,,facility,both,,,,147,110.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Nerve Conduction:3-4 Studies,9515145,CDM,922,RC,95908,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Nerve Conduction:5-6 Studies,9515146,CDM,922,RC,95909,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Nerve Conduction:7-8 Studies,9515147,CDM,922,RC,95910,HCPCS,,,facility,both,,,,278,208.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Nerve Conduction:9-10 Studies,9515148,CDM,922,RC,95911,HCPCS,,,facility,both,,,,512,384,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Nerve Conduction:11-12 Studies,9515149,CDM,922,RC,95912,HCPCS,,,facility,both,,,,512,384,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Nerve Conduction:13 Or More Studies,9515150,CDM,922,RC,95913,HCPCS,,,facility,both,,,,512,384,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Perc Translum Coro Angioplasty; Sngl Maj Cor Art Or Branch,9515159,CDM,480,RC,92920,HCPCS,,,facility,both,,,,16852,12639,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Perc Translum Coro Angioplasty; Ea Addl Branch; List Sep W/Primary Code,9515160,CDM,480,RC,92921,HCPCS,,,facility,both,,,,12499,9374.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Perc Ather W/Cor Angioplasty, Sngl Ves",9515161,CDM,480,RC,92924,HCPCS,,,facility,both,,,,41927,31445.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Cor Stent Plcmt W/Angioplasty,  Sngl",9515163,CDM,480,RC,92928,HCPCS,,,facility,both,,,,23917,17937.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Cor Stent Plcmt W/Angioplasty, Add",9515164,CDM,480,RC,92929,HCPCS,,,facility,both,,,,16175,12131.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Cor Atherectomy W/Stent,Angioplasty, Sngl Ves",9515165,CDM,480,RC,92933,HCPCS,,,facility,both,,,,24290,18217.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Revasc Cor Graft Any Combo/Ptca/Ath/Stent Sngl,9515167,CDM,480,RC,92937,HCPCS,,,facility,both,,,,18495,13871.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revasc Cto/Acute Mi Any Combo, Ptca/Ath/Stent  Incl Asp Thrombectomy Sngl",9515169,CDM,480,RC,92941,HCPCS,,,facility,both,,,,26023,19517.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revasc Cto, Any Combo,Ptca/Ath/Stent",9515170,CDM,480,RC,92943,HCPCS,,,facility,both,,,,20235,15176.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ep Eval W/Induct Arryth, Pacing, Svt Ablation",9515173,CDM,480,RC,93653,HCPCS,,,facility,both,,,,42320,31740,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ep Eval W/Induct Arryth, Pacing, Vt Ablation, And 3D Mapping When Perf",9515174,CDM,480,RC,93654,HCPCS,,,facility,both,,,,43531,32648.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Secondary Ablation, List Sep W/Primary Code",9515175,CDM,481,RC,93655,HCPCS,,,facility,both,,,,15228,11421,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ep Eval W/Ablation Afib By Pulm Vein Isolation,9515176,CDM,481,RC,93656,HCPCS,,,facility,both,,,,49778,37333.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Add Ablation After Pvi For Afib,9515177,CDM,480,RC,93657,HCPCS,,,facility,both,,,,17281,12960.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Retrieval Intravas Foreign Body,9515178,CDM,361,RC,37197,HCPCS,,,facility,both,,,,4904,3678,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Thrombolysis Ther, Art, Non Coro, Init Day",9515179,CDM,361,RC,37211,HCPCS,,,facility,both,,,,8559,6419.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Thrombolysis Ther, Ven, Non Coro Init Day",9515180,CDM,361,RC,37212,HCPCS,,,facility,both,,,,5828,4371,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Thrombo Ther, Art Or Ven, Cont Tx Subs Day, Incl Follow Up Cath Contrast, Pos Chg/Xchg",9515181,CDM,361,RC,37213,HCPCS,,,facility,both,,,,7637,5727.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Thrombo Ther, Art Or Ven, Incl Fu Contrast, Chg/Exchg, Reml And/Or Stop",9515182,CDM,361,RC,37214,HCPCS,,,facility,both,,,,7637,5727.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Poly Younger Than 6 Years, Sleep Staging With 4 Or More Para Of Sleep Attended By A Tech-Peds",9515193,CDM,740,RC,95782,HCPCS,,,facility,both,,,,7013,5259.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Poly Younger Than 6 Years With Continuous Positive Airway Pressure Therapy Or Bi-Level Vent-Peds,9515194,CDM,740,RC,95783,HCPCS,,,facility,both,,,,7013,5259.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Drug Eluting Stent Placement, Initial",9515195,CDM,481,RC,C9600,HCPCS,,,facility,both,,,,23917,17937.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Drug Eluting Stent Placing Additional,9515196,CDM,481,RC,C9601,HCPCS,,,facility,both,,,,16175,12131.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Coronary Atherectomy With Drug Eluting Stent Initial,9515197,CDM,480,RC,C9602,HCPCS,,,facility,both,,,,22033,16524.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Coronary Atherectomy With Drug Eluting Stent, Additional",9515198,CDM,480,RC,C9603,HCPCS,,,facility,both,,,,2427,1820.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revasc Graft W/Any Combo, Ptca/Atherectomy/Or Drug Eluting Stent, Initial",9515199,CDM,480,RC,C9604,HCPCS,,,facility,both,,,,27474,20605.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revasc Graft W/Any Combo, Ptca/Atherectomy/ Or Drug Eluting Stent, Additional",9515200,CDM,480,RC,C9605,HCPCS,,,facility,both,,,,2299,1724.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revasc Total/Subtotal Cto,Acute Mi W/Combo Ptca/Ather/Drug Eluting Stent, Incl Asp Thrombectomy",9515201,CDM,480,RC,C9606,HCPCS,,,facility,both,,,,26023,19517.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revasc Cto, Art Or Graft, W/Any Combo, Ptca/Ath/Or Drug Eluting Stent, Initial",9515202,CDM,481,RC,C9607,HCPCS,,,facility,both,,,,29592,22194,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revasc Cto, Art Or Graft, W/Any Combo, Ptca/Ath/Or Drug Eluting Stent, Add",9515203,CDM,480,RC,C9608,HCPCS,,,facility,both,,,,2582,1936.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xr Cspine 4 Or 5 Views (Specify Views),9515207,CDM,320,RC,72050,HCPCS,,,facility,both,,,,433,324.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Xr Cspine 4 Or 5 Views (Specify Views),9515207,CDM,320,RC,72050,HCPCS,,,facility,both,,,,433,324.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Xr Cspine +6 Views,9515208,CDM,320,RC,72052,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Nm Parathyroid Planar Imaging,9515212,CDM,341,RC,78070,HCPCS,,,facility,both,,,,1719,1289.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Angio Thor Aorta/Extrcran Carotid,Vert,Intrcran Vess; Uni Or Bil",9515214,CDM,361,RC,36221,HCPCS,,,facility,both,,,,7090,5317.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Angio Com Carotid/Innom Art; Uni, Cerv Cereb Arch",9515215,CDM,361,RC,36222,HCPCS,,,facility,both,,,,4053,3039.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Angio Com Carotid/Innom Art; Uni W/Extracran Carotid,9515216,CDM,361,RC,36223,HCPCS,,,facility,both,,,,4982,3736.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Angio Internal Carotid, Unilateral",9515217,CDM,361,RC,36224,HCPCS,,,facility,both,,,,8680,6510,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Angio Vertebral Artery, Unilat",9515219,CDM,361,RC,36226,HCPCS,,,facility,both,,,,9163,6872.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Angio Ext Carotid Art, Uni, In Add To Primary Code",9515220,CDM,361,RC,36227,HCPCS,,,facility,both,,,,4998,3748.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Angio Ea Intracran Branch Int Carotid Or Verteb Art Uni, In Add To Primary Code",9515221,CDM,361,RC,36228,HCPCS,,,facility,both,,,,2105,1578.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Hepatitis B Vacc Admin,9515285,CDM,771,RC,90471,HCPCS,,,facility,both,,,,81,60.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mhoc-Hepatitis B Vacc Admin,9515285,CDM,771,RC,90471,HCPCS,,,facility,both,,,,65,48.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Laryngoscopy,Dirct,Diagnostic",9515287,CDM,361,RC,31525,HCPCS,,,facility,both,,,,1640,1230,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Biopsy Vaginal Mucosa,Simple",9515289,CDM,361,RC,57100,HCPCS,,,facility,both,,,,665,498.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Psy Dx Interview,9515292,CDM,900,RC,90791,HCPCS,,,facility,both,,,,392,294,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Psy Dx Interview,9515292,CDM,900,RC,90791,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Psy Thx 20-30 Outpt Only,9515296,CDM,914,RC,90832,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Psy Thx 45-50 Outpt Only,9515298,CDM,914,RC,90834,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Psy Thx 75-80 Outpt Only,9515300,CDM,914,RC,90837,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Psy Family W/O Patient,9515301,CDM,916,RC,90846,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Psy Family W/Patient,9515302,CDM,916,RC,90847,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Psy Family W/Patient,9515302,CDM,916,RC,90847,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Psy Group Not Multi Fam Outpt,9515304,CDM,915,RC,90853,HCPCS,,,facility,both,,,,307,230.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Exploration Of Penetrating Wound, Extermity",9515309,CDM,361,RC,20103,HCPCS,,,facility,both,,,,1153,864.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Chemodenervation Of Muscle, Neck Muscle, Excl Muscles Of The Larynx, Unilateral",9515318,CDM,361,RC,64616,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Chemodenervation Of Muscle, Neck Muscle, Excl Muscles Of The Larynx, Unilateral",9515318_50,CDM,361,RC,64616,HCPCS,,,facility,both,,,50,411,308.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
"C Chemodenervation Of One Extremity, 1-4 Muscles",9515320,CDM,361,RC,64642,HCPCS,,,facility,both,,,,666,499.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Chemodenervation Of One Extremity, 5 Or More Muscles",9515321,CDM,361,RC,64644,HCPCS,,,facility,both,,,,666,499.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Chemodenervation Of Trunk Muscle, 1-5 Muscles",9515322,CDM,361,RC,64646,HCPCS,,,facility,both,,,,1670,1252.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Chemodenervation Of Trunk Muscle, 1-5 Muscles",9515322,CDM,361,RC,64646,HCPCS,,,facility,both,,,,666,499.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Chemodenervation Of Trunk Muscle, 6 Or More Muscles",9515323,CDM,361,RC,64647,HCPCS,,,facility,both,,,,2597,1947.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Chemodenervation Of Trunk Muscle, 6 Or More Muscles",9515323,CDM,361,RC,64647,HCPCS,,,facility,both,,,,666,499.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Chemodenervation Of One Extremity, Each Addtl Extremity, 1-4 Muscles",9515324,CDM,361,RC,64643,HCPCS,,,facility,both,,,,42,31.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Chemodenervation Of One Extremity, Each Addtl Extremity, 5 Or More Muscles",9515325,CDM,361,RC,64645,HCPCS,,,facility,both,,,,67,50.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C St-Eval Fluency,9515337,CDM,444,RC,92521,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St-Eval Speech Sound Production,9515338,CDM,444,RC,92522,HCPCS,,,facility,both,,,,379,284.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St-Eval Speech Sound Prod W/Lang Comphrhen,9515339,CDM,444,RC,92523,HCPCS,,,facility,both,,,,506,379.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St-Behavioral/Qualt Analysis Voice,9515340,CDM,444,RC,92524,HCPCS,,,facility,both,,,,424,318,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vasc Embolization Or Occlusion, Venous, Non Hemorrhage; Incl S&I, Roadmap, Image Guidance",9515360,CDM,361,RC,37241,HCPCS,,,facility,both,,,,22185,16638.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vasc Embolization Or Occl, Artery, Non Hemorrhage Or Tumor; Incl S&I, Roadmap, Image Guidance",9515361,CDM,361,RC,37242,HCPCS,,,facility,both,,,,24059,18044.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vasc Embolization Or Occl, Artery, Tumors, Organ Isch, Infarc; Incl S&I, Roadmap, Image Guid",9515362,CDM,361,RC,37243,HCPCS,,,facility,both,,,,28354,21265.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Vasc Emboliz Or Occl, Art Or Ven Hemorrhage Or Lymph Extrav; Incl S&I, Roadmap, Image Guid",9515363,CDM,361,RC,37244,HCPCS,,,facility,both,,,,30490,22867.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Intravas Stent Plcmnt Open Or Perc, Incl Angioplasty When Perf, W/S&I;  Init Artery",9515364,CDM,361,RC,37236,HCPCS,,,facility,both,,,,22879,17159.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Intravas Stent Plcmnt Open Or Perc, Non Lower Ext,Incl Angioplasty When Perf, W/S&I;  Add Art",9515365,CDM,361,RC,37237,HCPCS,,,facility,both,,,,8465,6348.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Intravas Stent Plcmnt Open Or Perc, Incl Angioplasty When Perf, W/S&I;  Init Vein",9515366,CDM,361,RC,37238,HCPCS,,,facility,both,,,,21743,16307.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Intravas Stent Plcmnt Open Or Perc, Non Lower Ext,Incl Angioplasty When Perf, W/S&I;  Add Vein",9515367,CDM,361,RC,37239,HCPCS,,,facility,both,,,,7361,5520.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Appl Lcs Sub Graft Trunk,Arm,Leg Total Up To 100 Sq Cm, First 25 Sq Cm Or Less Wound Surface",9515368,CDM,361,RC,C5271,HCPCS,,,facility,both,,,,2070,1552.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Appl Lcs Sub Graft Trunk,Arm,Leg Total Up To 100 Sq Cm, Ea Addtl 25 Sq Cm Wound Surface",9515369,CDM,361,RC,C5272,HCPCS,,,facility,both,,,,783,587.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Appl Lcs Sub Grft Head,Neck,Genit,Hnd,Fet Wnd To 100 Sq Cm,1St 25 Sq Cm Or Less Wnd Surf",9515372,CDM,361,RC,C5275,HCPCS,,,facility,both,,,,1044,783,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Appl Lcs Sub Grft Head,Neck,Genit,Hnd,Fet Wnd To 100 Sq Cm,Ea 25 Sq Cm Wound Surf",9515373,CDM,361,RC,C5276,HCPCS,,,facility,both,,,,783,587.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Bx Breast 1St Les Strtctc,9515376,CDM,361,RC,19081,HCPCS,,,facility,both,,,,3640,2730,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Bx Breast 1St Les Us Imag,9515377,CDM,361,RC,19083,HCPCS,,,facility,both,,,,3335,2501.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Bx Breast 1St Les Mr Imag,9515378,CDM,361,RC,19085,HCPCS,,,facility,both,,,,2645,1983.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Image Fluid Collection Drainage By Catheter; Visceral, Percutaneous",9515379,CDM,361,RC,49405,HCPCS,,,facility,both,,,,5236,3927,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Image Fluid Collect Drain By Cath; Peritoneal/Retroperitoneal, Percut",9515380,CDM,361,RC,49406,HCPCS,,,facility,both,,,,4472,3354,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Bx Breast Ea Addl Les Strtctc,9515383,CDM,361,RC,19082,HCPCS,,,facility,both,,,,1348,1011,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Bx Breast Ea Addl Les Us Imag,9515384,CDM,361,RC,19084,HCPCS,,,facility,both,,,,1587,1190.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Bx Breast Ea Addl Les Mr Imag,9515385,CDM,361,RC,19086,HCPCS,,,facility,both,,,,1348,1011,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Perq Dev 1St Les,9515386,CDM,361,RC,19281,HCPCS,,,facility,both,,,,2022,1516.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Perq Dev Ea Addl Les,9515387,CDM,361,RC,19282,HCPCS,,,facility,both,,,,922,691.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Perq Dev 1St Les Us,9515390,CDM,361,RC,19285,HCPCS,,,facility,both,,,,1516,1137,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Perq Dev Ea Addl Les Us,9515391,CDM,361,RC,19286,HCPCS,,,facility,both,,,,925,693.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Perq Dev 1St Les Mr,9515392,CDM,361,RC,19287,HCPCS,,,facility,both,,,,3618,2713.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Mam Perq Dev Ea Addl Les Mr,9515393,CDM,361,RC,19288,HCPCS,,,facility,both,,,,949,711.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Image Fluid Collection Drainage By Cath, Soft Tissue, Percut",9515397,CDM,361,RC,10030,HCPCS,,,facility,both,,,,1495,1121.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Echo Tthrc R-T 2D W/Wo M-Mode Complete Rest&St Wo/ Contrast,9515402,CDM,483,RC,93350,HCPCS,,,facility,both,,,,1268,951,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ndl Emg Guidance W/Chemodenervation,9515404,CDM,922,RC,95874,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Demonstrate Use Home Inr Monitor,9515405,CDM,920,RC,G0248,HCPCS,,,facility,both,,,,452,339,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Provide Inr Test Materials/Equipmt,9515406,CDM,920,RC,G0249,HCPCS,,,facility,both,,,,360,270,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Dress And/Or Debrid Of Part-Thick Burns 1St/Susq Small (< 5% Total Body Surface Area),9515414,CDM,761,RC,16020,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Dress And/Or Debrid Of Part-Thick Burns 1St/Susq Small (< 5% Total Body Surface Area),9515414,CDM,761,RC,16020,HCPCS,,,facility,both,,,,417,312.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Dress And/Or Debrid Of Part-Thick Burns 1St/Susq Small (< 5% Total Body Surface Area),9515414,CDM,761,RC,16020,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Dress And/Or Debrid Of Part-Thick Burns 1St/Susq Med (Whole Face/Extremity, >5% <10% Body Surface)",9515415,CDM,761,RC,16025,HCPCS,,,facility,both,,,,545,408.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Dress And/Or Debrid Of Part-Thick Burns 1St/Susq Large (>1 Extremity, Or  >10% Body Surface)",9515416,CDM,761,RC,16030,HCPCS,,,facility,both,,,,782,586.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Debridement, Subcutaneous Tissue (Includes Epidermis And Dermis, If Performed) First 20 Sq Cm Or L",9515417,CDM,761,RC,11042,HCPCS,,,facility,both,,,,1000,750,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Debridement, Subcutaneous Tissue (Includes Epidermis And Dermis, If Performed) First 20 Sq Cm Or L",9515417,CDM,761,RC,11042,HCPCS,,,facility,both,,,,1000,750,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Debridement, Subcutaneous Tissue (Includes Epidermis And Dermis, If Performed) First 20 Sq Cm Or L",9515417,CDM,761,RC,11042,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Debridemnt,Muscle,Or Fascia,First 20 Sq Cm Or Less",9515418,CDM,761,RC,11043,HCPCS,,,facility,both,,,,983,737.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Debridemnt,Muscle,Or Fascia,First 20 Sq Cm Or Less",9515418,CDM,761,RC,11043,HCPCS,,,facility,both,,,,539,404.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Debridemnt,Bone, First 20 Sq Cm Or Less",9515419,CDM,761,RC,11044,HCPCS,,,facility,both,,,,2530,1897.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Debridement, Subcutaneous Tissue (Includes Epidermis And Dermis, If Performed) Ea Addl 20 Sq Cm, O",9515420,CDM,761,RC,11045,HCPCS,,,facility,both,,,,800,600,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Debridement, Subcutaneous Tissue (Includes Epidermis And Dermis, If Performed) Ea Addl 20 Sq Cm, O",9515420,CDM,761,RC,11045,HCPCS,,,facility,both,,,,26,19.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Debridemnt,Muscle,Or Fascia,Ea Addtl 20 Sq Cm",9515421,CDM,761,RC,11046,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"C Debridemnt,Muscle,Or Fascia,Ea Addtl 20 Sq Cm",9515421,CDM,761,RC,11046,HCPCS,,,facility,both,,,,54,40.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Incision & Drainage Abscess Complicated/Multiple,9515423,CDM,361,RC,10061,HCPCS,,,facility,both,,,,720,540,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Incision & Drainage Abscess Complicated/Multiple,9515423,CDM,361,RC,10061,HCPCS,,,facility,both,,,,720,540,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Incision & Drainage Abscess Complicated/Multiple,9515423,CDM,361,RC,10061,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Paring Or Cutting Of Benign Hyperkeratotic Lesion (Eg, Corn Or Callus); Single Lesion",9515425,CDM,361,RC,11055,HCPCS,,,facility,both,,,,766,574.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Paring Or Cutting Of Benign Hyperkeratotic Lesion (Eg, Corn Or Callus); Single Lesion",9515425,CDM,361,RC,11055,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Paring/Cutting Benign Hyperkeratotic Lesion,2 To 4 Lesions",9515426,CDM,361,RC,11056,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Application Rigid Total Contact Leg Cast,9515430,CDM,761,RC,29445,HCPCS,,,facility,both,,,,851,638.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Application Unna Boot,9515431,CDM,761,RC,29580,HCPCS,,,facility,both,,,,584,438,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Trim Nondystrophic Nails,Any Number",9515432,CDM,361,RC,11719,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Trim Nondystrophic Nails,Any Number",9515432,CDM,361,RC,11719,HCPCS,,,facility,both,,,,158,118.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Debridement Nail(S) By Any Method 1 To 5,9515433,CDM,761,RC,11720,HCPCS,,,facility,both,,,,211,158.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Debridement Nail(S) By Any Method 1 To 5,9515433,CDM,761,RC,11720,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Debridement Nail(S) By Any Method 6 Or More,9515434,CDM,761,RC,11721,HCPCS,,,facility,both,,,,59,44.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Avulsion Nail Plate,Partialor Comp,Single",9515435,CDM,361,RC,11730,HCPCS,,,facility,both,,,,353,264.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Avulsion Nail Plate,Partialor Comp,Single",9515435,CDM,361,RC,11730,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Avulsion Nail Plate,Partialor Comp,Single",9515435,CDM,361,RC,11730,HCPCS,,,facility,both,,,,353,264.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Avulsion Nail Plate,Partialor Comp,Ea Addtl Nail Plate",9515436,CDM,361,RC,11732,HCPCS,,,facility,both,,,,121,90.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Apply Skin Substitute Graft Trunk,Arm,Leg, Surf Area Up To 100 Sq Cm,First 25 Sq Cm",9515438,CDM,361,RC,15271,HCPCS,,,facility,both,,,,3505,2628.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Apply Skin Substitute Graft Face,Scalp,Eyelid,Mouth,Neck,Surf Area Up To 100 Sq Cm,First 25 Sq Cm",9515439,CDM,361,RC,15275,HCPCS,,,facility,both,,,,3306,2479.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Neg Press Wound Thrpy, W/Non-Dme,Topicl Applc,Wound Assessmt,Per Session, < Or Eq To 50 Sq Cm",9515447,CDM,761,RC,97607,HCPCS,,,facility,both,,,,805,603.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Neg Press Wound Thrpy, W/Non-Dme,Topicl Applc,Wound Assessmt,Per Session, > 50 Sq Cm",9515448,CDM,761,RC,97608,HCPCS,,,facility,both,,,,1035,776.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Chemodenervation Of Muscle, Innervated By Facial, Trigeminal, Cervical Spinal And Accessory Nerve",9515449,CDM,361,RC,64615,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Nerve Block,Injection,Anes Agent,Sphenopalatine Ganglion",9515450,CDM,361,RC,64505,HCPCS,,,facility,both,,,,936,702,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Nerve Block,Injection,Anes Agent,Sphenopalatine Ganglion",9515450,CDM,361,RC,64505,HCPCS,,,facility,both,,,,936,702,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Hyperbaric Oxygen,9515466,CDM,413,RC,G0277,HCPCS,,,facility,both,,,,417,312.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Imrt Simple, Intensity Modulated Radiation Treatment Delivery Includes Guidance And Tracking",9515479,CDM,333,RC,77385,HCPCS,,,facility,both,,,,1669,1251.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Guidance For Localization Of Target Volume For Delivery Of Radiation Treatment Delivery,9515481,CDM,333,RC,77387,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiation Treatment Delivery, =1 Mev; Complex",9515485,CDM,333,RC,77412,HCPCS,,,facility,both,,,,915,686.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Insert/Repl Subq Icd W/Electrode, Induction Of Arrythmia, &  Progamming",9515486,CDM,361,RC,33270,HCPCS,,,facility,both,,,,54735,41051.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Program Device Eval In Person Subq Defib System,9515491,CDM,480,RC,93260,HCPCS,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Interrog Device Eval In Person W/Analysis W/& W/O Changes Subq Defib System,9515492,CDM,480,RC,93261,HCPCS,,,facility,both,,,TC,61,45.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier TC: Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha"
C Ep Evaluation Subq Icd & Programming,9515493,CDM,480,RC,93644,HCPCS,,,facility,both,,,,2899,2174.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ecmo)/Ecls Provided By Physician; Daily Management, Each Day, Veno-Venous",9515496,CDM,361,RC,33948,HCPCS,,,facility,both,,,,512,384,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ecmo)/Ecls Provided By Physician; Daily Management, Each Day, Veno-Arterial",9515497,CDM,361,RC,33949,HCPCS,,,facility,both,,,,497,372.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Perq Vertebroplasty , 1 Vertebral Body, Uni Or Bil Inj, Inclusive All Imag Guid; Cervicothoracic",9515518,CDM,361,RC,22510,HCPCS,,,facility,both,,,,8242,6181.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Perq Vertebroplasty, 1 Verte Body, Uni Or Bil Inj, Inclusive All Imaging Guide; Lumbosac",9515519,CDM,361,RC,22511,HCPCS,,,facility,both,,,,8242,6181.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Perq Vert Aug, Incl Cavity Creat (Fx Red & Bone Bx Incl) 1 Vert Body, Uni Or Bil Can;  Thoracic",9515521,CDM,361,RC,22513,HCPCS,,,facility,both,,,,18042,13531.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Perq Vert Aug, Incl Cavity Creat (Fx Red & Bone Bx Incl), 1 Vert Body, Uni Or Bil Can; Lumbar",9515522,CDM,361,RC,22514,HCPCS,,,facility,both,,,,21652,16239,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Perq Vertebral Augmentation, 1 Vertebral Body, Uni/Bil Cann, Ea Add Thoracic/Lumbar Vert Body",9515523,CDM,361,RC,22515,HCPCS,,,facility,both,,,,14060,10545,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Screening Digital Breast Tomosynthesis, Bilateral",9515526,CDM,403,RC,77063,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Us, Breast, Unilateral, Real Time W Image Documentation, Including Axilla When Performed; Complete",9515527,CDM,402,RC,76641,HCPCS,,,facility,both,,,,436,327,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Us, Breast, Unilateral, Real Time W Image Documentation, Including Axilla When Performed; Limited",9515528,CDM,402,RC,76642,HCPCS,,,facility,both,,,,399,299.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Us, Breast, Unilateral, Real Time W Image Documentation, Including Axilla When Performed; Limited",9515528,CDM,402,RC,76642,HCPCS,,,facility,both,,,,399,299.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Us, Breast, Unilateral, Real Time W Image Documentation, Including Axilla When Performed; Limited",9515528,CDM,402,RC,76642,HCPCS,,,facility,both,,,,399,299.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Us, Breast, Unilateral, Real Time W Image Documentation, Including Axilla When Performed; Limited",9515528_50,CDM,402,RC,76642,HCPCS,,,facility,both,,,50,598,448.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
"Us, Breast, Unilateral, Real Time W Image Documentation, Including Axilla When Performed; Limited",9515528_50,CDM,402,RC,76642,HCPCS,,,facility,both,,,50,598,448.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
"Hc Arthrocentesis, Aspiration And/Or Inj, Small Joint/Bursa; W Us Guid, W Perm Recording/Reporting",9515529,CDM,361,RC,20604,HCPCS,,,facility,both,,,,748,561,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Arthrocentesis, Aspiration And/Or Inj, Small Joint/Bursa; W Us Guid, W Perm Recording/Reporting",9515529,CDM,361,RC,20604,HCPCS,,,facility,both,,,,748,561,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arthrohcentesis, Aspirati &/Or Inj, Intermediate Joint Or Bursa W Us Guid, W Perm Rehcord & Repor",9515530,CDM,361,RC,20606,HCPCS,,,facility,both,,,,1173,879.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arthrohcentesis, Aspirati &/Or Inj, Intermediate Joint Or Bursa W Us Guid, W Perm Rehcord & Repor",9515530,CDM,361,RC,20606,HCPCS,,,facility,both,,,,1173,879.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Arthrohcentesis,Aspiration And/Or Inj, Major Joint Or Bursa;W Us Guide, W Permanent Rehcord & Rep",9515531,CDM,361,RC,20611,HCPCS,,,facility,both,,,,1535,1151.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Arthrohcentesis,Aspiration And/Or Inj, Major Joint Or Bursa;W Us Guide, W Permanent Rehcord & Rep",9515531,CDM,361,RC,20611,HCPCS,,,facility,both,,,,440,330,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Arthrohcentesis,Aspiration And/Or Inj, Major Joint Or Bursa;W Us Guide, W Permanent Rehcord & Rep",9515531,CDM,361,RC,20611,HCPCS,,,facility,both,,,,1535,1151.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Arthrohcentesis,Aspiration And/Or Inj, Major Joint Or Bursa;W Us Guide, W Permanent Rehcord & Rep",9515531_50,CDM,361,RC,20611,HCPCS,,,facility,both,,,50,660,495,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure
"C Myelography Via Lumbar Injection, Including Radiological Supervision And Interpretation; Cervical",9515532,CDM,361,RC,62302,HCPCS,,,facility,both,,,,3000,2250,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Myelography Via Lumbar Injection, Including Radiological Supervision And Interpretation; Thoracic",9515533,CDM,361,RC,62303,HCPCS,,,facility,both,,,,3000,2250,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Myelography Via Lumbar Injection, Including Radsupervision And Interpretation; Lumbosacral",9515534,CDM,361,RC,62304,HCPCS,,,facility,both,,,,2178,1633.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Myelography Via Lumbar Inj, Including Radiological Supervision And Interpretation; 2 Or >",9515535,CDM,361,RC,62305,HCPCS,,,facility,both,,,,3171,2378.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Percu Sacral Augme, Uni Inj(S), Including The Use Of Balloon/Mechanical Device, When Used, 1 Or >",9515538,CDM,361,RC,0200T,HCPCS,,,facility,both,,,,7130,5347.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Percut Sacral Augment, Bil Inj, Including The Use Of Balloon/Mechanical Device, When Used, 2 Or >",9515539,CDM,361,RC,0201T,HCPCS,,,facility,both,,,,7130,5347.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Excision, Malignant Lesion Incl Margins, Trunk, Arms, Or Legs; Excised Diameter 2.1-3.0 Cm (11603)",9515542,CDM,361,RC,11603,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Digital Breast Tomosynthesis,9515543,CDM,401,RC,G0279,HCPCS,,,facility,both,,,,82,61.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Hb Home Sleep Study - Dot (Pdx),9515552,CDM,740,RC,95806,HCPCS,,,facility,both,,,,506,379.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Hb Home Sleep Study - Dot (Pdx),9515552,CDM,740,RC,95806,HCPCS,,,facility,both,,,,690,517.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Change Of Cystostomy Tube; Simple,9515555,CDM,361,RC,51705,HCPCS,,,facility,both,,,,742,556.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Change Of Cystostomy Tube; Simple,9515555,CDM,361,RC,51705,HCPCS,,,facility,both,,,,742,556.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Ir Change Cystostomy Tube,Complicated",9515556,CDM,361,RC,51710,HCPCS,,,facility,both,,,,1649,1236.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Fitting And Insertion Of Pessary Or Other Intravaginal Support Device,9515566,CDM,330,RC,57160,HCPCS,,,facility,both,,,,179,134.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Aspiration/Injection Ganglion Cyst(S),9515574,CDM,361,RC,20612,HCPCS,,,facility,both,,,,644,483,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Injection Procedure Congenital Heart Arterial/Graft ( Add-On),9515576,CDM,481,RC,93564,HCPCS,,,facility,both,,,,315,236.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iv Infusion Therapy Prophylaxis/ Dx Initial To Up To 1 Hr,9515578,CDM,260,RC,96365,HCPCS,,,facility,both,,,,726,544.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Iv Infusion Therapy Prophylaxis/ Dx Initial To Up To 1 Hr,9515578,CDM,260,RC,96365,HCPCS,,,facility,both,,,,726,544.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iv Infusion Therapy Prophylaxis/Dx Ea Hour,9515579,CDM,260,RC,96366,HCPCS,,,facility,both,,,,224,168,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iv Infusion Therapy Prophylaxis/Dx Ea Hour,9515579,CDM,260,RC,96366,HCPCS,,,facility,both,,,,224,168,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Iv Infusion Ther Proph Addl Sequential To 1 Hr,9515580,CDM,260,RC,96367,HCPCS,,,facility,both,,,,276,207,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iv Infusion Ther Proph Addl Sequential To 1 Hr,9515580,CDM,260,RC,96367,HCPCS,,,facility,both,,,,276,207,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Iv Infusion Therapy Prophylaxis/Dx Concurrent,9515581,CDM,260,RC,96368,HCPCS,,,facility,both,,,,211,158.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iv Infusion Therapy Prophylaxis/Dx Concurrent,9515581,CDM,260,RC,96368,HCPCS,,,facility,both,,,,211,158.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Ivpush/15 Min/Less Initial,9515582,CDM,260,RC,96374,HCPCS,,,facility,both,,,,380,285,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ivpush/15 Min/Less Initial,9515582,CDM,260,RC,96374,HCPCS,,,facility,both,,,,380,285,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Ivpush/15 Min/Less Initial,9515582,CDM,260,RC,96374,HCPCS,,,facility,both,,,,236,177,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Ivpush/New Drug/ Addl,9515583,CDM,260,RC,96375,HCPCS,,,facility,both,,,,247,185.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Ivpush/New Drug/ Addl,9515583,CDM,260,RC,96375,HCPCS,,,facility,both,,,,247,185.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ivpush/Same Drug/Addl,9515584,CDM,260,RC,96376,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ivpush/Same Drug/Addl,9515584,CDM,260,RC,96376,HCPCS,,,facility,both,,,,181,135.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Iv Infusion Hydration Initial (31 -60 Min),9515585,CDM,260,RC,96360,HCPCS,,,facility,both,,,,592,444,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iv Infusion Hydration Initial (31 -60 Min),9515585,CDM,260,RC,96360,HCPCS,,,facility,both,,,,592,444,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Iv Infusion Hydration Each Additional (Greater Than 91 Min),9515586,CDM,260,RC,96361,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Iv Infusion Hydration Each Additional (Greater Than 91 Min),9515586,CDM,260,RC,96361,HCPCS,,,facility,both,,,,178,133.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Paravertebral Block,Thoracic,Single Injection (Inc Guidance)",9515587,CDM,361,RC,64461,HCPCS,,,facility,both,,,,2597,1947.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Excision,Benign Lesion Including Margins, Except Skin Tag, Trunk, Arms, Legs <5 Cm",9515604,CDM,361,RC,11400,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Exc Skin Benig 0.6-1Cm Trunk,Arm,Leg 11401",9515605,CDM,361,RC,11401,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet",9515606,CDM,361,RC,12031,HCPCS,,,facility,both,,,,650,487.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet",9515606,CDM,361,RC,12031,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet",9515607,CDM,361,RC,12032,HCPCS,,,facility,both,,,,720,540,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet",9515607,CDM,361,RC,12032,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Biopsy Vulva/Perineum,One Lesn 56605",9515608,CDM,361,RC,56605,HCPCS,,,facility,both,,,,665,498.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Colposcopy W/ Biopsy 57454,9515611,CDM,361,RC,57454,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Endometrial Biopsy 58100,9515613,CDM,361,RC,58100,HCPCS,,,facility,both,,,,179,134.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Removal Of Intrauterine Device (Iud),9515616,CDM,361,RC,58301,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Removal Of Intrauterine Device (Iud),9515616,CDM,361,RC,58301,HCPCS,,,facility,both,,,,376,282,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Telehealth Facility Fee Q3014,9515617,CDM,780,RC,Q3014,HCPCS,,,facility,both,,,,125,93.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Incision Of Tongue Fold, Lingual Frenum (Frenotomy) 41010",9515629,CDM,361,RC,41010,HCPCS,,,facility,both,,,,1647,1235.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Exchange Nephrostomy Catheter,Perct,Diagn Nephrostogram/Ureterogram,W/Imaging Guidance",9515633,CDM,361,RC,50435,HCPCS,,,facility,both,,,,2118,1588.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Spine,Entire Thoracic/Lumbar, Inc Skull,Cervical,Sacral Spine:2 Or 3 Views",9515635,CDM,320,RC,72082,HCPCS,,,facility,both,,,,339,254.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Hip,Unilateral,W/Pelvis(When Performed):1 View",9515636,CDM,320,RC,73501,HCPCS,,,facility,both,,,,256,192,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Hip,Unilateral,W/Pelvis(When Performed):1 View",9515636,CDM,320,RC,73501,HCPCS,,,facility,both,,,,256,192,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Hip,Unilateral W/Pelvis (When Performed):2-3 Views",9515637,CDM,320,RC,73502,HCPCS,,,facility,both,,,,257,192.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Hip,Unilateral W/Pelvis (When Performed):2-3 Views",9515637,CDM,320,RC,73502,HCPCS,,,facility,both,,,,257,192.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Hip,Unilateral W/Pelvis (When Performed):Min 4 Views",9515638,CDM,320,RC,73503,HCPCS,,,facility,both,,,,295,221.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Hip,Bilateral W/Pelvis (When Performed):2 Views",9515639,CDM,320,RC,73521,HCPCS,,,facility,both,,,,417,312.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Hip,Bilateral W/Pelvis (When Performed):2 Views",9515639,CDM,320,RC,73521,HCPCS,,,facility,both,,,,417,312.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Hip,Bilateral W/Pelvis (When Performed):3-4 Views",9515640,CDM,320,RC,73522,HCPCS,,,facility,both,,,,441,330.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Xr Hip,Bilateral W/Pelvis (When Performed):3-4 Views",9515640,CDM,320,RC,73522,HCPCS,,,facility,both,,,,441,330.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Xr Hip,Bilateral W/Pelvis (When Performed):Min 5 Views",9515641,CDM,320,RC,73523,HCPCS,,,facility,both,,,,700,525,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Femur:2 Views,9515642,CDM,320,RC,73552,HCPCS,,,facility,both,,,,257,192.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Femur:2 Views,9515642,CDM,320,RC,73552,HCPCS,,,facility,both,,,,257,192.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Inj Procedure Cholangiography Perct,Complete Diagnostic Procedure W/Imaging Guidance",9515643,CDM,361,RC,47531,HCPCS,,,facility,both,,,,2488,1866,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Placement Nephrostomy Catheter,Perct,Diagn Nephrostogram/Ureterogram,W/Imaging Guidance",9515644,CDM,361,RC,50432,HCPCS,,,facility,both,,,,5870,4402.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ivus (Noncoronary) W/S&I Initial Vessel,9515647,CDM,361,RC,37252,HCPCS,,,facility,both,,,,4725,3543.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ir Inj Proc Cholangiography,Perct, Compl Diag Procedure,Inc Imaging Guidance:New Access",9515652,CDM,361,RC,47532,HCPCS,,,facility,both,,,,3532,2649,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ir Rem Calculi From Biliary Duct,Gallbladder,Perct,Inc Destrctn Calculi,Guidance (Add-On-Code)",9515653,CDM,361,RC,47544,HCPCS,,,facility,both,,,,4727,3545.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ir Plcmnt Ureteral Stent,Perc,Inc Diag Nephrosto/Ureterogram ,Guide:Pre-Existing Nephrostomy Trac",9515655,CDM,361,RC,50693,HCPCS,,,facility,both,,,,9086,6814.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ir Plcmnt Ureteral Stent,Perc,Diag Nephrosto/Ureterogram,Guide:New Access W/O Sep Nephrostomy Cat",9515656,CDM,361,RC,50694,HCPCS,,,facility,both,,,,7198,5398.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ir Plcmnt Ureteral Stent,Perct,Diag Nephrosto/Ureterogram,Guide:New Access,W/Sep Nephrostomy",9515657,CDM,361,RC,50695,HCPCS,,,facility,both,,,,5643,4232.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ir Placement Biliary Drain Catheter,Perct,Inc Diag Cholangiography,Guidance,External",9515658,CDM,361,RC,47533,HCPCS,,,facility,both,,,,3965,2973.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ir Placement Biliary Drain Catheter,Perct,Inc Diag Cholangiography,Guidance:Internal-External",9515659,CDM,361,RC,47534,HCPCS,,,facility,both,,,,7354,5515.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ir Conv Extnl Biliary Drain Cath To Internal-External Biliary Drain Cath,Perc,Diag Cholangio,Guid",9515660,CDM,361,RC,47535,HCPCS,,,facility,both,,,,9658,7243.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ir Exchange Biliary Drain Catheter,Perc,Inc Diag Cholangiography,Guidance",9515661,CDM,361,RC,47536,HCPCS,,,facility,both,,,,4606,3454.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ir Removal Biliary Drain Catheter,Perc,Req Fluoro Guidance,Inc Diag Cholangiography,Guidance",9515662,CDM,361,RC,47537,HCPCS,,,facility,both,,,,1984,1488,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Ir Plcmnt Stent Bile Duct,Perc,Inc Cholangio,Guide,Bal Dil,Cath Exch&Rem,Ea Stent:Existing Access",9515663,CDM,361,RC,47538,HCPCS,,,facility,both,,,,10007,7505.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ir Plcmt Stent Bile,Perc,Inc Cholangio,Bal Dil,Cath Exch&Rem,Ea Stent:New W/O Plcmt Sep Bil Drain",9515664,CDM,361,RC,47539,HCPCS,,,facility,both,,,,8967,6725.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ir Plcmt Stent Bile ,Perc,Inc Cholangio,Bal Dil,Cath Exch&Rem,Ea Stent:New W/Plcmt Sep Bil Drain",9515665,CDM,361,RC,47540,HCPCS,,,facility,both,,,,9591,7193.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Inj Proced Antegrade Nephro/Ureterogram, Complete Dx Procedure, Imag Guid, Rad S&I; New Access",9515668,CDM,361,RC,50430,HCPCS,,,facility,both,,,,2628,1971,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Inj Proced Antegrade Neph/Ureterogram, Complete Dx Procedure, Imag Guid, Rad S&I; Existing Access",9515669,CDM,361,RC,50431,HCPCS,,,facility,both,,,,838,628.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Cnvrt Nephro Cath To Nephrouret Cath, Perc, Dx Neph/Ureterogram, Imag Guid, R S&I, Exist N-Ostomy",9515670,CDM,361,RC,50434,HCPCS,,,facility,both,,,,1109,831.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Ir Balloon Dilation,Ureteral Stricture, Inc Image Guidance (Add-On-Code)",9515677,CDM,361,RC,50706,HCPCS,,,facility,both,,,,2916,2187,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Radiopharmaceutical Therapy,By Intra-Arterial Particulate Admin",9515679,CDM,342,RC,79445,HCPCS,,,facility,both,,,,1153,864.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Balloon Dilat Bil Duct, Ampulla, Perc, Include Imag Guid, Rad S&I, Each Duct",9515680,CDM,361,RC,47542,HCPCS,,,facility,both,,,,3341,2505.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Sclerotx Fluid Collection, Perc, Includ Contrast Inj, Sclerosant Inj, Dx Study, Imag Guid, Rad S&",9515683,CDM,361,RC,49185,HCPCS,,,facility,both,,,,2951,2213.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Echo, Transthorac,Real-Time W Image Doc (2D), Incld M-Mode",9515710,CDM,483,RC,93351,HCPCS,,,facility,both,,,,1491,1118.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Trauma Activation Full-Rc 683,9515719,CDM,683,RC,G0390,HCPCS,,,facility,both,,,,6232,4674,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Trauma Activation Full-Rc 683,9515719,CDM,683,RC,G0390,HCPCS,,,facility,both,,,,6232,4674,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Trauma Activation Full-Rc 683 (Without Critical Care),9515720,CDM,683,RC,,,,,facility,both,,,,5665,4248.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Trauma Activation Full-Rc 683 (Without Critical Care),9515720,CDM,683,RC,,,,,facility,both,,,,5665,4248.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Bronchoscopy W/Ebus Sampling 1 Or 2 Lymph Node Stations/Structures,9515744,CDM,361,RC,31652,HCPCS,,,facility,both,,,,472,354,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Osteopathic Manip,1-2 Body R",9515757,CDM,940,RC,98925,HCPCS,,,facility,both,,,,28,21,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Removal Imp Cerumen (1 Or Both Ears) On Same Dos As Audiologic Fnt Tst,9515762,CDM,761,RC,G0268,HCPCS,,,facility,both,,,,32,24,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Dxa Bone Density/Peripheral,9515763,CDM,320,RC,77081,HCPCS,,,facility,both,,,,290,217.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Psychotherapy For Crisis; First 60 Minutes,9515770,CDM,914,RC,90839,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Laa Closure W/Implant,9515781,CDM,481,RC,33340,HCPCS,,,facility,both,,,,36624,27468,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Transluminal Balloon Angioplasty,Inc Image/S&I/Interpretation, Within Same Artery,Initial Artery",9515788,CDM,361,RC,37246,HCPCS,,,facility,both,,,,15882,11911.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Intro Ndl/Cathtr W/Diagnost Angio Dialysis Circuit,W/Translum Balloon Angio,Inc All Imaging,S&I",9515789,CDM,361,RC,36902,HCPCS,,,facility,both,,,,21664,16248,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Transluminal Balloon Angio,Perform Thru Dialysis Circuit,Inc All Imaging/S&I,Angioplasty,Add-On",9515790,CDM,361,RC,36907,HCPCS,,,facility,both,,,,8896,6672,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Transluminal Balloon Angio,Open Or Percut,Inc All Imaging/S&I:Angio Within Same Vein:Initial Vein",9515791,CDM,361,RC,37248,HCPCS,,,facility,both,,,,15800,11850,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Intro Ndl/Cath W/Diag Angio Dialysis Circt,Inc All Punctr&Cath Plcmmt,Inj Contrst,Image/Fluoro/S&",9515792,CDM,361,RC,36901,HCPCS,,,facility,both,,,,1879,1409.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Percut Translmnl Mech Thromb/Inf Thromb,Circuit,Any Method,Inc Al Image W/Translumnl Balloon Angio",9515793,CDM,361,RC,36905,HCPCS,,,facility,both,,,,32683,24512.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Percut Translmnl Mech Thromb/Inf Thromb,Circuit,Any Method,Inc Image W/Transcath Plcmnt Vasc Sten",9515794,CDM,361,RC,36906,HCPCS,,,facility,both,,,,38273,28704.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Translmnl Ball Angio(Exc Lower Ext Artry)Open/Percut,Inc Image/S&I,Angio Same Artery:Ea Addt,Addon",9515795,CDM,361,RC,37247,HCPCS,,,facility,both,,,,7961,5970.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Intro Ndl/Cath W/Diagnostic Angio Dialysis Circuit,Placmnt Vascular Stent,Inc All Imaging",9515796,CDM,361,RC,36903,HCPCS,,,facility,both,,,,25873,19404.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Transcatheter Plcmnt Vasc Stent,Dialysis Circuit,Inc All Imaging,Perform Stent,All Angio Segment",9515797,CDM,361,RC,36908,HCPCS,,,facility,both,,,,13946,10459.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Percut Translmnl Mech/Inf Thromb,Dc,Any Method,Inc All Image,Cath Placemnt/Intrprocedrl Thromb In",9515798,CDM,361,RC,36904,HCPCS,,,facility,both,,,,8691,6518.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Diagnostic Mammography, Including Computer-Aided Detection (Cad) When Performed; Unilateral",9515800,CDM,401,RC,77065,HCPCS,,,facility,both,,,,334,250.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Diagnostic Mammography, Including Computer-Aided Detection (Cad) When Performed; Bilateral",9515801,CDM,401,RC,77066,HCPCS,,,facility,both,,,,426,319.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Screening Mammography, Bilateral (2-View Study Of Each Breast), Including Cad When Performed",9515802,CDM,403,RC,77067,HCPCS,,,facility,both,,,,335,251.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Us Abdominal Aorta, Real Time With Image Documentation, Screening Study For Aaa",9515803,CDM,402,RC,76706,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Us Abdominal Aorta, Real Time With Image Documentation, Screening Study For Aaa",9515803,CDM,402,RC,76706,HCPCS,,,facility,both,,,,546,409.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt Eval Low Complexity,9515806,CDM,424,RC,97161,HCPCS,,,facility,both,,,,225,168.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt Eval Moderate Complexity,9515807,CDM,424,RC,97162,HCPCS,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt Eval High Complexity,9515808,CDM,424,RC,97163,HCPCS,,,facility,both,,,,289,216.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt Re-Eval,9515809,CDM,424,RC,97164,HCPCS,,,facility,both,,,,210,157.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot Eval Low Complexity,9515810,CDM,434,RC,97165,HCPCS,,,facility,both,,,,240,180,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot Eval Moderate Complexity,9515811,CDM,434,RC,97166,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot Eval High Complexity,9515812,CDM,434,RC,97167,HCPCS,,,facility,both,,,,328,246,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot Re-Eval,9515813,CDM,434,RC,97168,HCPCS,,,facility,both,,,,208,156,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Transluminal Balloon Angio,Open Or Perct,Inc All Imaging/S&I:Angio Within Same Vein:Each Addl Vei",9515815,CDM,361,RC,37249,HCPCS,,,facility,both,,,,6787,5090.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Insertion,Non-Biodegradable Drug Delivery Implant",9515818,CDM,361,RC,11981,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Removal,Non-Biodegradable Drug Delivery Implant",9515819,CDM,361,RC,11982,HCPCS,,,facility,both,,,,385,288.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Dialysis Circuit Permanent Vascular Emboli/Occlusion, Endovascular,Inc All Imaging- Add-On",9515821,CDM,361,RC,36909,HCPCS,,,facility,both,,,,11713,8784.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Inj(S) Diag/Thera Subst(S),Epidural/Subarachnoid,Lumbar/Sacral(Caudal),W/Imaging Guidance",9515822,CDM,361,RC,62323,HCPCS,,,facility,both,,,,1427,1070.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Tavr Prosthetic Valve:Percutaneous Femoral Artery Approach,9515824,CDM,480,RC,33361,HCPCS,,,facility,both,,,,36149,27111.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Tavr Prosthetic Valve:Percutaneous Open Femoral Artery Approach,9515825,CDM,480,RC,33362,HCPCS,,,facility,both,,,,37866,28399.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Tavr Prosthetic Valve:Open Axillary Artery Approach,9515826,CDM,480,RC,33363,HCPCS,,,facility,both,,,,3293,2469.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Tavr Prosthetic Valve:Open Iliac Artery Approach,9515827,CDM,480,RC,33364,HCPCS,,,facility,both,,,,41274,30955.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Tavr Prosthetic Valve:Transaortic Approach,9515828,CDM,480,RC,33365,HCPCS,,,facility,both,,,,39750,29812.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Tavr Prosthetic Valve:Cardiopulmonary Bypass Support W/Open Peripheral/Arterial/Venous (Add-On),9515831,CDM,480,RC,33368,HCPCS,,,facility,both,,,,20656,15492,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Tavr Prosthetic Valve:Cardiopulmonary Bypass Support W/Central Arterial/Venous (Add-On),9515832,CDM,480,RC,33369,HCPCS,,,facility,both,,,,26852,20139,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Therapeutic Plateletpheresis,9515835,CDM,361,RC,36513,HCPCS,,,facility,both,,,,2479,1859.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Proc-Unsched Peritoneal Dialysis Esrd Pt,9515840,CDM,830,RC,G0257,HCPCS,,,facility,both,,,,1268,951,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pulmonary Stress Test (6Min),9515841,CDM,460,RC,94618,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pulmonary Stress Test (6Min),9515841,CDM,460,RC,94618,HCPCS,,,facility,both,,,,130,97.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Diagnostic Bone Marrow,Biopsy(S) And Aspiration(S)",9515842,CDM,361,RC,38222,HCPCS,,,facility,both,,,,2799,2099.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Diagnostic Bone Marrow,Biopsy(S) And Aspiration(S)",9515842,CDM,361,RC,38222,HCPCS,,,facility,both,,,,2745,2058.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Ir Endoluminal Bx Bil Tree, Perc, Includ Imag  Guid, Rad S & I, Sgl Or Multiple",9515846,CDM,361,RC,47543,HCPCS,,,facility,both,,,,2364,1773,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Chest Single View,9515847,CDM,324,RC,71045,HCPCS,,,facility,both,,,,242,181.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Chest Single 2 Views,9515848,CDM,324,RC,71046,HCPCS,,,facility,both,,,,281,210.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Chest Single 3 Views,9515849,CDM,324,RC,71047,HCPCS,,,facility,both,,,,323,242.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Chest Single 4 Or More Views,9515850,CDM,324,RC,71048,HCPCS,,,facility,both,,,,354,265.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Abdomen 1 View,9515851,CDM,320,RC,74018,HCPCS,,,facility,both,,,,281,210.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Abdomen 2 Views,9515852,CDM,320,RC,74019,HCPCS,,,facility,both,,,,299,224.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Xr Abdomen 3 Or More Views,9515853,CDM,320,RC,74021,HCPCS,,,facility,both,,,,469,351.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Peripheral Arterial Disease(Pad) Rehab,Per Session",9515859,CDM,480,RC,93668,HCPCS,,,facility,both,,,,175,131.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Pt Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min,9515861,CDM,420,RC,97763,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min,9515862,CDM,430,RC,97763,HCPCS,,,facility,both,,,,146,109.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Endovascular Repair Deployment Aorto-Bi-Iliac ,Other Than Rupture",9515879,CDM,361,RC,34705,HCPCS,,,facility,both,,,,19062,14296.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Percutaneous Access/Closure Femoral Artery Large Sheath(12Fr&Larger),Inc Us,Unilateral-Add-On",9515881,CDM,361,RC,34713,HCPCS,,,facility,both,,,,1907,1430.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Endovascular Repair Of Descending Thoracic Aorta, Involving Coverage Of Left Sub Artery - 75956",9515882,CDM,323,RC,75956,HCPCS,,,facility,both,,,,728,546,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Rt Maximum Breathing Capacity, Maximal Voluntary Ventilation",9515889,CDM,460,RC,94200,HCPCS,,,facility,both,,,,332,249,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Amputation Finger Thumb Single W Direct Closure,9515892,CDM,361,RC,26951,HCPCS,,,facility,both,,,,3416,2562,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Amputation Finger Thumb Single W Direct Closure,9515892,CDM,361,RC,26951,HCPCS,,,facility,both,,,,3416,2562,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Medial Malleolus Fracture; W Manipulation, W Wo Skin Or Skeletal Traction",9515893,CDM,361,RC,27762,HCPCS,,,facility,both,,,,2804,2103,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Drainage Of Finger Abscess; Complicated,9515895,CDM,361,RC,26011,HCPCS,,,facility,both,,,,1782,1336.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Incision And Drainage Of Submucosal Abscess, Rectum",9515900,CDM,361,RC,45005,HCPCS,,,facility,both,,,,3038,2278.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Shoulder Dislocation, W Manipulation; Requiring Anesthesia",9515901,CDM,361,RC,23655,HCPCS,,,facility,both,,,,3564,2673,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Excision, Benign Lesion Including Margins, Except Skin Tag, Trunk, Arms Or Legs, 1.1-2.0 Cm",9515903,CDM,361,RC,11402,HCPCS,,,facility,both,,,,826,619.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Excision, Benign Lesion Including Margins, Except Skin Tag, Trunk, Arms Or Legs, 1.1-2.0 Cm",9515903,CDM,361,RC,11402,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Closed Tx Supracondylar Transcondylar Humeral Fx W Manip,9515904,CDM,361,RC,24535,HCPCS,,,facility,both,,,,2255,1691.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Closure Of Laceration, Vestibule Of Mouth; 2.5 Cm Or Less",9515905,CDM,361,RC,40830,HCPCS,,,facility,both,,,,759,569.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Of Nasal Bone Fracture; Wo Stabilization,9515906,CDM,361,RC,21315,HCPCS,,,facility,both,,,,2778,2083.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Of Temporomandibular Dislocation; Initial Or Subsequent,9515907,CDM,361,RC,21480,HCPCS,,,facility,both,,,,575,431.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Shoulder Dislocation, W Fracture Of Greater Humeral Tuberosity, W Manipulation",9515908,CDM,361,RC,23665,HCPCS,,,facility,both,,,,1826,1369.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Treatment Of Articular Fracture, Involving Metacarpophalangeal Or Interphalangeal Joint; Wi",9515909,CDM,361,RC,26742,HCPCS,,,facility,both,,,,3587,2690.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Of Radial Head Or Neck Fracture; W Manipulation,9515910,CDM,361,RC,24655,HCPCS,,,facility,both,,,,1794,1345.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Carpometacarpal Dislocation, Other Than Thumb, W Manipulation, Ea Joint; Wo Anesth",9515913,CDM,361,RC,26670,HCPCS,,,facility,both,,,,466,349.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Distal Phalangeal Fracture, Finger Or Thumb; W Manipulation, Each",9515914,CDM,361,RC,26755,HCPCS,,,facility,both,,,,604,453,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Closd Tx Distal Fibular Fx W Manipulation,9515915,CDM,450,RC,27788,HCPCS,,,facility,both,,,,932,699,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Of Metatarsophalangeal Joint Dislocation; Wo Anesthesia,9515916,CDM,361,RC,28630,HCPCS,,,facility,both,,,,408,306,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Simple Repair Of  Wounds Of Scalp, Neck, Axillae, External Genitalia, Trunk, Extrm Over 30 Cm",9515917,CDM,361,RC,12007,HCPCS,,,facility,both,,,,1121,840.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Drainage External Auditory Canal, Abscess",9515919,CDM,361,RC,69020,HCPCS,,,facility,both,,,,816,612,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Drainage External Auditory Canal, Abscess",9515919,CDM,361,RC,69020,HCPCS,,,facility,both,,,,816,612,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Unlisted Procedure, Casting Or Strapping",9515921,CDM,361,RC,29799,HCPCS,,,facility,both,,,,404,303,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C  Control Nose/Throat Bleed Simple,9515922,CDM,361,RC,42970,HCPCS,,,facility,both,,,,1028,771,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Removal Of Embedded Foreign Body, Vestibule Of Mouth; Simple",9515924,CDM,361,RC,40804,HCPCS,,,facility,both,,,,978,733.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Trim Nails,9515929,CDM,450,RC,11719,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ed - Trim Nails,9515929,CDM,450,RC,11719,HCPCS,,,facility,both,,,,77,57.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Insert Picc Line Without Imaging Guidance,9515935,CDM,450,RC,36569,HCPCS,,,facility,both,,,,3779,2834.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Fx Weight Bearing Distal Tibia Int Fix,9515942,CDM,361,RC,27825,HCPCS,,,facility,both,,,,3056,2292,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Drainage Of Scrotal Wall Abscess,9515943,CDM,361,RC,55100,HCPCS,,,facility,both,,,,2553,1914.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closure Of Laceration, Vestibule Of Mouth; Over 2.5 Cm Or Complex",9515944,CDM,361,RC,40831,HCPCS,,,facility,both,,,,2054,1540.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Of Radial Shaft Fracture; W Manipulation,9515945,CDM,361,RC,25505,HCPCS,,,facility,both,,,,2003,1502.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Drainage Abscess Or Hematoma, Nasal, Internal Approach",9515946,CDM,361,RC,30000,HCPCS,,,facility,both,,,,236,177,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Tx Of Wound Dehiscence; Simple Closure,9515947,CDM,361,RC,12020,HCPCS,,,facility,both,,,,1000,750,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Tx Of Wound Dehiscence; Simple Closure,9515947,CDM,361,RC,12020,HCPCS,,,facility,both,,,,549,411.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Repair, Complx, Forehead, Cheeks,Chin,Mouth,Neck,Axillae,Genitalia,Hands,Feet, 1.1-2.5 Cm",9515948,CDM,361,RC,13131,HCPCS,,,facility,both,,,,1566,1174.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Unlisted Procedure, Dentoalveolar Structures",9515949,CDM,361,RC,41899,HCPCS,,,facility,both,,,,665,498.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair Of Laceration 2.5 Cm Or Less; Floor Of Mouth, Anterior Two-Thirds Of Tongue",9515951,CDM,361,RC,41250,HCPCS,,,facility,both,,,,637,477.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Humeral Shaft Fracture; W Manipulation, W Wo Skeletal Traction",9515952,CDM,361,RC,24505,HCPCS,,,facility,both,,,,2208,1656,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Fracture Great Toe, Phalanx Or Phalanges; W Manipulation",9515953,CDM,361,RC,28495,HCPCS,,,facility,both,,,,450,337.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Complex, Eyelids, Nose, Ears And/Or Lips; Each Additional 5 Cm Or Less",9515954,CDM,361,RC,13153,HCPCS,,,facility,both,,,,799,599.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Placement Of Needle For Intraosseous Infusion,9515956,CDM,361,RC,36680,HCPCS,,,facility,both,,,,535,401.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Anoscopy; Dx, Include Collection Of Specimens By Brushing, Washing, When Performed",9515958,CDM,361,RC,46600,HCPCS,,,facility,both,,,,366,274.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Anoscopy; Dx, Include Collection Of Specimens By Brushing, Washing, When Performed",9515958,CDM,361,RC,46600,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Perc Arterial Catheterization Sampling Monitoring,9515959,CDM,361,RC,36620,HCPCS,,,facility,both,,,,647,485.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Perc Arterial Catheterization Sampling Monitoring,9515959,CDM,361,RC,36620,HCPCS,,,facility,both,,,,647,485.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Remove Drug Implant Device,9515961,CDM,450,RC,11982,HCPCS,,,facility,both,,,,607,455.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Ed - Explore Wound, Extremity",9515963,CDM,450,RC,20103,HCPCS,,,facility,both,,,,1153,864.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Insertion Of Chest Tube,9515966,CDM,450,RC,32551,HCPCS,,,facility,both,,,,1685,1263.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ed - Insertion Of Chest Tube,9515966,CDM,450,RC,32551,HCPCS,,,facility,both,,,,1495,1121.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Insert Cath Pleura W/O Image,9515967,CDM,450,RC,32556,HCPCS,,,facility,both,,,,4643,3482.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Inject Epidural Patch,9515970,CDM,450,RC,62273,HCPCS,,,facility,both,,,,1932,1449,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair Of Laceration Of Tongue, Floor Of Mouth, Over 2.6 Cm Or Complex",9515974,CDM,361,RC,41252,HCPCS,,,facility,both,,,,2016,1512,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair Lip, Full Thickness; Over One-Half Vertical Height, Or Complex",9515975,CDM,361,RC,40654,HCPCS,,,facility,both,,,,2807,2105.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Tibial Shaft Fracture W Wo Fibular Fracture; W Manipulation, W Wo Skeletal Traction",9515976,CDM,361,RC,27752,HCPCS,,,facility,both,,,,3284,2463,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Blepharotomy, Drainage Of Abscess, Eyelid",9515977,CDM,361,RC,67700,HCPCS,,,facility,both,,,,776,582,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Irrigation Of Corpora Cavernosa For Priapism,9515978,CDM,361,RC,54220,HCPCS,,,facility,both,,,,680,510,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Incision And Drainage Of Bartholins Gland Abscess,9515979,CDM,361,RC,56420,HCPCS,,,facility,both,,,,585,438.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Drainage External Ear, Abscess Or Hematoma; Simple",9515980,CDM,361,RC,69000,HCPCS,,,facility,both,,,,869,651.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair Blood Vessel, Direct; Lower Extremity",9515985,CDM,361,RC,35226,HCPCS,,,facility,both,,,,1686,1264.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Closd Tx Bimalleolar Ankle Fx W Manipulation,9515987,CDM,450,RC,27810,HCPCS,,,facility,both,,,,1849,1386.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Hip Dislocation, Traumatic; Wo Anesthesia",9515988,CDM,361,RC,27250,HCPCS,,,facility,both,,,,605,453.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Repair, Complex, Forehead,Cheeks,Chin,Mouth,Neck,Axillae,Genitalia,Hands,Feet; 2.6-7.5 Cm",9515991,CDM,361,RC,13132,HCPCS,,,facility,both,,,,1495,1121.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk, Extrm; 12.6-20 Cm",9515992,CDM,361,RC,12035,HCPCS,,,facility,both,,,,1024,768,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk, Extrm; 12.6-20 Cm",9515992,CDM,361,RC,12035,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Repair, Intermediate, Wounds Face, Ears, Eyelids, Nose, Lips , Mucous Membranes; 7.6-12.5 Cm",9515993,CDM,361,RC,12054,HCPCS,,,facility,both,,,,978,733.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Of Interphalangeal Joint Dislocation; Wo Anesthesia,9515994,CDM,361,RC,28660,HCPCS,,,facility,both,,,,472,354,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Simple Repair Wounds Of Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; 7.6-12.5 Cm",9515995,CDM,361,RC,12015,HCPCS,,,facility,both,,,,849,636.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Drainage Of Abscess, Cyst, Hematoma, Vestibule Of Mouth; Simple",9515996,CDM,361,RC,40800,HCPCS,,,facility,both,,,,787,590.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; 5.1-7.5 Cm",9516000,CDM,361,RC,12053,HCPCS,,,facility,both,,,,920,690,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Complex, Forehead,Cheeks,Chin,Mouth,Neck,Axillae,Genitalia,Hands,Feet, Ea Addl 5 Cm",9516001,CDM,361,RC,13133,HCPCS,,,facility,both,,,,680,510,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Fracture, Phalanx Or Phalanges, Other Than Great Toe; W Manipulation, Each",9516002,CDM,361,RC,28515,HCPCS,,,facility,both,,,,634,475.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Nasal/Sinus Endoscopy, Surgical; W Control Of Nasal Hemorrhage",9516003,CDM,361,RC,31238,HCPCS,,,facility,both,,,,1568,1176,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C  Control Nosebleed Posterior W Nasal Packs Initial,9516004,CDM,361,RC,30905,HCPCS,,,facility,both,,,,453,339.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Mod Sed Diff Phy >5 1St 15Min,9516006,CDM,450,RC,99156,HCPCS,,,facility,both,,,,427,320.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Complex, Scalp, Arms, And/Or Legs; 2.6-7.5 Cm",9516007,CDM,361,RC,13121,HCPCS,,,facility,both,,,,1173,879.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Complex, Scalp, Arms, And/Or Legs; 2.6-7.5 Cm",9516007,CDM,361,RC,13121,HCPCS,,,facility,both,,,,808,606,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Drainage Of Finger Abscess; Simple,9516008,CDM,361,RC,26010,HCPCS,,,facility,both,,,,552,414,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Drainage Of Finger Abscess; Simple,9516008,CDM,361,RC,26010,HCPCS,,,facility,both,,,,552,414,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Drainage Of Finger Abscess; Simple,9516008,CDM,361,RC,26010,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Simple Repair Of Wounds Of Scalp, Neck, Axillae, External Genitalia, Trunk, Extrm, 20.1-30 Cm",9516010,CDM,361,RC,12006,HCPCS,,,facility,both,,,,842,631.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Control Nasal Hemorrhage, Anterior, Complex (Extensive Cautery And/Or Pahcking) Any Method",9516011,CDM,361,RC,30903,HCPCS,,,facility,both,,,,419,314.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Control Nasal Hemorrhage, Anterior, Complex (Extensive Cautery And/Or Pahcking) Any Method",9516011,CDM,361,RC,30903,HCPCS,,,facility,both,,,,419,314.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Control Nasal Hemorrhage, Anterior, Complex (Extensive Cautery And/Or Pahcking) Any Method",9516011,CDM,361,RC,30903,HCPCS,,,facility,both,,,,119,89.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Unlisted Procedure, Pharynx, Adenoids, Or Tonsils",9516013,CDM,361,RC,42999,HCPCS,,,facility,both,,,,616,462,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Of Patellar Dislocation; Wo Anesthesia,9516014,CDM,361,RC,27560,HCPCS,,,facility,both,,,,651,488.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or Ext Genitalia; 2.5 Cm Or Less",9516015,CDM,361,RC,12041,HCPCS,,,facility,both,,,,513,384.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or Ext Genitalia; 2.5 Cm Or Less",9516015,CDM,361,RC,12041,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Initial Tx, First Degree Burn",9516017,CDM,361,RC,16000,HCPCS,,,facility,both,,,,310,232.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Initial Tx, First Degree Burn",9516017,CDM,361,RC,16000,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ed - Control Throat Bleeding,9516018,CDM,450,RC,42960,HCPCS,,,facility,both,,,,4407,3305.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Abd Paracentsis W/Imaging,9516019,CDM,450,RC,49083,HCPCS,,,facility,both,,,,2162,1621.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ed - Abd Paracentsis W/Imaging,9516019,CDM,450,RC,49083,HCPCS,,,facility,both,,,,2162,1621.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incision Thrombosed Hemorrhoid External,9516022,CDM,361,RC,46083,HCPCS,,,facility,both,,,,620,465,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incision Thrombosed Hemorrhoid External,9516022,CDM,361,RC,46083,HCPCS,,,facility,both,,,,713,534.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Phalangeal Shaft Fx Finger Thumb W Manip W Wo Skeletal Traction Ea,9516023,CDM,361,RC,26725,HCPCS,,,facility,both,,,,673,504.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Of Ankle Dislocation; Wo Anesthes,9516024,CDM,361,RC,27840,HCPCS,,,facility,both,,,,742,556.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Tx Of Closed Elbow Dislocation; Wo Anesthesia,9516025,CDM,361,RC,24600,HCPCS,,,facility,both,,,,805,603.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Simple Repair Wounds Of Scalp, Neck, Axillae, Extgenitalia, Trunk, Extrm, 12.6-20 Cm",9516028,CDM,361,RC,12005,HCPCS,,,facility,both,,,,812,609,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Of Radial And Ulnar Shaft Fractures; W Manipulation,9516031,CDM,361,RC,25565,HCPCS,,,facility,both,,,,1973,1479.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Wedge Excision Of Skin Of Nail Fold,9516032,CDM,361,RC,11765,HCPCS,,,facility,both,,,,365,273.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Wedge Excision Of Skin Of Nail Fold,9516032,CDM,361,RC,11765,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Repair, Complex, Eyelids, Nose, Ears And/Or Lips; 2.6 Cm To 7.5 Cm",9516033,CDM,361,RC,13152,HCPCS,,,facility,both,,,,1560,1170,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Complex, Eyelids, Nose, Ears And/Or Lips; 2.6 Cm To 7.5 Cm",9516033,CDM,361,RC,13152,HCPCS,,,facility,both,,,,549,411.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Closed Tx Of Post Hip Arthroplasty Dislocation; Wo Anesthesia,9516034,CDM,361,RC,27265,HCPCS,,,facility,both,,,,616,462,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk, Extrm; 7.6-12.5 Cm",9516036,CDM,361,RC,12034,HCPCS,,,facility,both,,,,750,562.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Scalp, Axillae, Trunk, Extrm; 7.6-12.5 Cm",9516036,CDM,361,RC,12034,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Closed Tx Of Trimalleolar Ankle Fracture; W Manipula,9516037,CDM,361,RC,27818,HCPCS,,,facility,both,,,,1662,1246.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or Ext Genitalia; 2.6-7.5 Cm",9516040,CDM,361,RC,12042,HCPCS,,,facility,both,,,,650,487.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or Ext Genitalia; 2.6-7.5 Cm",9516040,CDM,361,RC,12042,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or Ext Genitalia; 2.6-7.5 Cm",9516040,CDM,361,RC,12042,HCPCS,,,facility,both,,,,650,487.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Removal Of Foreign Body, External Eye; Corneal, Wo Slit Lamp",9516041,CDM,361,RC,65220,HCPCS,,,facility,both,,,,447,335.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Removal Of Foreign Body, External Eye; Corneal, W Slit Lamp",9516042,CDM,361,RC,65222,HCPCS,,,facility,both,,,,470,352.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Evacuation Of Subungual Hematoma,9516043,CDM,361,RC,11740,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Evacuation Of Subungual Hematoma,9516043,CDM,361,RC,11740,HCPCS,,,facility,both,,,,137,102.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Complex, Scalp, Arms, And/Or Legs; Each Addl 5 Cm Or Less",9516045,CDM,361,RC,13122,HCPCS,,,facility,both,,,,575,431.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Repair Of Nail Bed,9516049,CDM,361,RC,11760,HCPCS,,,facility,both,,,,791,593.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Repair Of Nail Bed,9516049,CDM,361,RC,11760,HCPCS,,,facility,both,,,,791,593.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Simple Repair Of  Wounds Of Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; 5.1-7.5 Cm",9516050,CDM,361,RC,12014,HCPCS,,,facility,both,,,,828,621,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Removal Of Foreign Body, External Eye; Conjunctival Supe",9516051,CDM,361,RC,65205,HCPCS,,,facility,both,,,,348,261,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Metacarpal Fracture, Single; W Manipulation, Each Bone",9516052,CDM,361,RC,26605,HCPCS,,,facility,both,,,,833,624.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; Up-2.5 Cm",9516053,CDM,361,RC,12051,HCPCS,,,facility,both,,,,618,463.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; Up-2.5 Cm",9516053,CDM,361,RC,12051,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Intubation, Endotracheal, Emergency Procedure",9516054,CDM,361,RC,31500,HCPCS,,,facility,both,,,,1213,909.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Incision And Drainage Abscess; Peritonsillar,9516055,CDM,361,RC,42700,HCPCS,,,facility,both,,,,677,507.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Incision And Drainage Abscess; Peritonsillar,9516055,CDM,361,RC,42700,HCPCS,,,facility,both,,,,779,584.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Incision And Drainage Of Vulva Or Perineal Abscess,9516056,CDM,361,RC,56405,HCPCS,,,facility,both,,,,672,504,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Incision And Drainage Of Vulva Or Perineal Abscess,9516056,CDM,361,RC,56405,HCPCS,,,facility,both,,,,296,222,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Repair, Intermediate, Wounds Of Face, Ears, Eyelids, Nose, Lips , Mucous Membranes; 2.6-5 Cm",9516057,CDM,361,RC,12052,HCPCS,,,facility,both,,,,750,562.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Repair, Intermediate, Wounds Of Face, Ears, Eyelids, Nose, Lips , Mucous Membranes; 2.6-5 Cm",9516057,CDM,361,RC,12052,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Removal Impacted Cerumen Irrigation/Lvg Unilat,9516059,CDM,361,RC,69209,HCPCS,,,facility,both,,,,120,90,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Removal Impacted Cerumen Irrigation/Lvg Unilat,9516059,CDM,361,RC,69209,HCPCS,,,facility,both,,,,85,63.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Closed Tx Of Interphalangeal Joint Dislocation, Single, W Manipulation; Wo Anesthesia",9516061,CDM,361,RC,26770,HCPCS,,,facility,both,,,,713,534.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Radial Head Subluxation In Child, Nursemaid Elbow, W Manipulation",9516064,CDM,361,RC,24640,HCPCS,,,facility,both,,,,690,517.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Drainage Of Abscess, Cyst, Hematoma From Dentoalveolar Structures",9516068,CDM,361,RC,41800,HCPCS,,,facility,both,,,,475,356.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Simple Repair Wounds Of Scalp, Neck, Axillae, Ext Genitalia, Trunk, Extrm, 7.6-12.5 Cm",9516073,CDM,361,RC,12004,HCPCS,,,facility,both,,,,661,495.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Shoulder Dislocation, W Manipulation; Wo Anesthesia",9516075,CDM,361,RC,23650,HCPCS,,,facility,both,,,,978,733.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Distal Radial Fx W Closd Tx Ulnar Styloid Fx When Performed W Manip,9516078,CDM,361,RC,25605,HCPCS,,,facility,both,,,,2131,1598.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Distal Radial Fx W Closd Tx Ulnar Styloid Fx When Performed W Manip,9516078,CDM,361,RC,25605,HCPCS,,,facility,both,,,,1460,1095,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Simple Repair Of Wounds Of Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; 2.6-5 Cm",9516085,CDM,361,RC,12013,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Simple Repair Of Wounds Of Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; 2.6-5 Cm",9516085,CDM,361,RC,12013,HCPCS,,,facility,both,,,,620,465,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Ed - Application Of Short Arm Splint (Forearm To Hand), Static",9516087,CDM,450,RC,29125,HCPCS,,,facility,both,,,,483,362.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Simple Repair Of Wounds Scalp, Neck, Axillae, Ext Genitalia, Trunk, Extrm, 2.6-7.5 Cm",9516089,CDM,361,RC,12002,HCPCS,,,facility,both,,,,539,404.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Simple Repair Of Wounds Scalp, Neck, Axillae, Ext Genitalia, Trunk, Extrm, 2.6-7.5 Cm",9516089,CDM,361,RC,12002,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Simple Repair Of Wounds Of Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; Up-2.5 Cm",9516090,CDM,361,RC,12011,HCPCS,,,facility,both,,,,589,441.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Simple Repair Of Wounds Of Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; Up-2.5 Cm",9516090,CDM,361,RC,12011,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Ed - Bladder Scan Limited,9516091,CDM,450,RC,51798,HCPCS,,,facility,both,,,,251,188.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Binocular Microscopy Sep Dx Px,9516094,CDM,361,RC,92504,HCPCS,,,facility,both,,,,39,29.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Removal Of Skin Tags, Multiple Fibrocutaneous Tags, Any Area; Up To And Including 15 Lesions",9516095,CDM,361,RC,11200,HCPCS,,,facility,both,,,,238,178.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Removal Of Skin Tags, Multiple Fibrocutaneous Tags, Any Area; Up To And Including 15 Lesions",9516095,CDM,361,RC,11200,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Endovascular Ablation Therapy Incompetent Vein,Extremity,Inc All Imaging Guidance,First Vein",9516101,CDM,361,RC,36475,HCPCS,,,facility,both,,,,13173,9879.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Wound Prep Trk/Arm/Leg,9516106,CDM,761,RC,15002,HCPCS,,,facility,both,,,,7725,5793.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Wound Prep F/N/Hf/G,9516107,CDM,761,RC,15004,HCPCS,,,facility,both,,,,723,542.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Njx Sclrsnt Mlt Incmptnt Vn,9516111,CDM,361,RC,36471,HCPCS,,,facility,both,,,,386,289.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Njx Sclrsnt Mlt Incmptnt Vn,9516111,CDM,361,RC,36471,HCPCS,,,facility,both,,,,1362,1021.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Simple Repair Superficial Wounds Of Scalp, Neck, Axillae, External Genitalia, Trunk Or Extremities",9516118,CDM,761,RC,12001,HCPCS,,,facility,both,,,,540,405,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Us Infant Hips Limited Static,9516120,CDM,402,RC,76886,HCPCS,,,facility,both,,,,634,475.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Analyze Neurostim, Simple",9516121,CDM,920,RC,95971,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Gi Procedure Level 1, Initial 15 Minutes",9516128,CDM,750,RC,,,,,facility,both,,,,3011,2258.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Gi Procedure Level 1, Additional 15 Minutes",9516129,CDM,750,RC,,,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Gi Procedure Level 2, Initial 15 Minutes",9516130,CDM,750,RC,,,,,facility,both,,,,3011,2258.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Gi Procedure Level 2, Additional 15 Minutes",9516131,CDM,750,RC,,,,,facility,both,,,,343,257.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Gi Procedure Level 3, Initial 15 Minutes",9516132,CDM,750,RC,,,,,facility,both,,,,3011,2258.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Gi Procedure Level 3, Additional 15 Minutes",9516133,CDM,750,RC,,,,,facility,both,,,,838,628.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Gi Procedure Level 4, Initial 15 Minutes",9516134,CDM,750,RC,,,,,facility,both,,,,3011,2258.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Gi Procedure Level 4, Additional 15 Minutes",9516135,CDM,750,RC,,,,,facility,both,,,,865,648.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Injection Sclerosant:Single Incompetent Vein (Other Than Telangiectasia),9516154,CDM,361,RC,36470,HCPCS,,,facility,both,,,,1594,1195.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Injection Sclerosant:Single Incompetent Vein (Other Than Telangiectasia),9516154,CDM,361,RC,36470,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Insertion Of Ventricular Assist Device, Percutaneous Including Radiological Supervision And Inter",9516157,CDM,361,RC,33990,HCPCS,,,facility,both,,,,10474,7855.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Endovascular Repair Descending Thoracic Aorta,Inc Left Subclavian Artery",9516160,CDM,361,RC,33880,HCPCS,,,facility,both,,,,3845,2883.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Outpt Renal Dialysis Non-Ersrd,9516169,CDM,829,RC,90935,HCPCS,,,facility,both,,,,2558,1918.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Inpt Hemodialysis,9516174,CDM,801,RC,90935,HCPCS,,,facility,both,,,,2558,1918.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Myocardial Spect Multiple Studies - 78452,9516181,CDM,341,RC,78452,HCPCS,,,facility,both,,,,5060,3795,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Nm Myocardial Spect Multiple Studies - 78452,9516181,CDM,341,RC,78452,HCPCS,,,facility,both,,,,3457,2592.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Closed Tx Of Talus Fracture; W Manipulation,9516182,CDM,361,RC,28435,HCPCS,,,facility,both,,,,2196,1647,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Removal Of Percutaneous Left Heart Ventricular Assist Device, Arterial Or Arterial And Venous Can",9516188,CDM,361,RC,33992,HCPCS,,,facility,both,,,,1576,1182,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Biopsy,Muscle:Deep",9516189,CDM,361,RC,20205,HCPCS,,,facility,both,,,,2745,2058.75,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
"C Biopsy,Muscle:Deep",9516189,CDM,361,RC,20205,HCPCS,,,facility,both,,,,2745,2058.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Repair, Intermediate, Wounds Of Neck, Hands, Feet And/Or Ext Genitalia; 7.6-12.5 Cm",9516191,CDM,361,RC,12044,HCPCS,,,facility,both,,,,1000,750,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Femoral Fracture, Distal End, Medial Or Lateral Condyle, W Manipulation",9516200,CDM,361,RC,27510,HCPCS,,,facility,both,,,,2063,1547.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Partial Excision Bone; Distal Phalanx Of Finger,9516202,CDM,361,RC,26236,HCPCS,,,facility,both,,,,2438,1828.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Partial Excision Bone; Distal Phalanx Of Finger,9516202,CDM,361,RC,26236,HCPCS,,,facility,both,,,,2438,1828.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Echo Tee Guide Of Transcatheter  Intracardiac Or Great Vessel Structural Intervention(S),9516205,CDM,483,RC,93355,HCPCS,,,facility,both,,,,2587,1940.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Insertion,Subcut Cardiac Rhythm Monitor,Inc Programming",9516206,CDM,361,RC,33285,HCPCS,,,facility,both,,,,18063,13547.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Removal,Subcut Cardiac Rhythm Monitor",9516207,CDM,361,RC,33286,HCPCS,,,facility,both,,,,1962,1471.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Transcatheter Insert/Replacemnt Permanent Leadless Pacmakr,Rt Ventric W/Image Guidance,Device Eval",9516208,CDM,361,RC,33274,HCPCS,,,facility,both,,,,29840,22380,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Closed Tx Of Carpometacarpal Dislocation, Thumb, W Manipulation",9516211,CDM,361,RC,26641,HCPCS,,,facility,both,,,,616,462,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Replacement Of Gastrostomy Tube, Percutaneous, Includes Removal, When Performed, Without Imaging O",9516212,CDM,361,RC,43762,HCPCS,,,facility,both,,,,743,557.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Replacement Of Gastrostomy Tube, Percutaneous, Includes Removal, When Performed, Without Imaging O",9516212,CDM,361,RC,43762,HCPCS,,,facility,both,,,,279,209.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Replacement Of Gastrostomy Tube, Percutaneous, Includes Removal, When Performed, Without Imaging O",9516212,CDM,361,RC,43762,HCPCS,,,facility,both,,,,743,557.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Repair Extensor Tendon Finger W/O Graft Each,9516218,CDM,361,RC,26418,HCPCS,,,facility,both,,,,3381,2535.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Repair Extensor Tendon Finger W/O Graft Each,9516218,CDM,361,RC,26418,HCPCS,,,facility,both,,,,3381,2535.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Application Of On-Body Injector (Includes Cannula Insertion) For Timed Sq Im,9516222,CDM,260,RC,96377,HCPCS,,,facility,both,,,,237,177.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Chemotherapy Admin, Iv Infusion Tech; Initiation Of Infusion In The Office/Clinic Setting",9516224,CDM,280,RC,G0498,HCPCS,,,facility,both,,,,1353,1014.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Venipuncture,3Yrs &>,Necessiting Skill Physician/Qual Hlthcare Prof,Diagnostic/Therapeutic Purpose",9516225,CDM,761,RC,36410,HCPCS,,,facility,both,,,,518,388.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Venipuncture,3Yrs &>,Necessiting Skill Physician/Qual Hlthcare Prof,Diagnostic/Therapeutic Purpose",9516225,CDM,761,RC,36410,HCPCS,,,facility,both,,,,518,388.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Ultrasound,Elastography:Parenchyma (Eg,Organ)",9516236,CDM,402,RC,76981,HCPCS,,,facility,both,,,,362,271.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Mri,Breast,W/Out Contrast Material:Unilateral",9516237,CDM,610,RC,77046,HCPCS,,,facility,both,,,,2595,1946.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mri,Breast,W/Out Contrast Material:Bilateral",9516238,CDM,610,RC,77047,HCPCS,,,facility,both,,,,3436,2577,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Mri,Breast,W/Out And With Contrast Material,Inc Cad,When Performed:Unilateral",9516239,CDM,610,RC,77048,HCPCS,,,facility,both,,,,3384,2538,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Mri,Breast,W/Out And With Contrast Material,Inc Cad,When Performed:Bilateral",9516240,CDM,610,RC,77049,HCPCS,,,facility,both,,,,3469,2601.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fine Needle Aspiration Biopsy,Inc Ultrasound Guidance,First Lesion",9516241,CDM,361,RC,10005,HCPCS,,,facility,both,,,,1270,952.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Fine Needle Aspiration Biopsy,Inc Ultrasound Guidance,First Lesion",9516241,CDM,361,RC,10005,HCPCS,,,facility,both,,,,652,489,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"Hc Fine Needle Aspiration Biopsy,Inc Ultrasound Guidance,Ea Addtl Lesion (Add-On)",9516242,CDM,361,RC,10006,HCPCS,,,facility,both,,,,854,640.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Inj Procedure Contrast Knee Arthrography Or Contrast Enchance Ct/Mri Knee Arthrography,9516249,CDM,361,RC,27369,HCPCS,,,facility,both,,,,644,483,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Insertion Picc,W/Out Subcutaneous Port Or Pump,Inc All Image Guidance,S&I, <5 Years Age",9516250,CDM,361,RC,36572,HCPCS,,,facility,both,,,,3364,2523,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Insertion Picc,W/Out Subcutaneous Port Or Pump,Inc All Image Guidance,S&I, >5 Years Age",9516251,CDM,361,RC,36573,HCPCS,,,facility,both,,,,4082,3061.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Dilation Existng Tract,Percut,Urologic Proc W/Image Guide,S&I,W/Tube Placemt,New Renal Collect Sys",9516253,CDM,361,RC,50437,HCPCS,,,facility,both,,,,6779,5084.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Tangential Biopsy Of Skin (Eg,Shave,Scoop,Saucerize,Curette):Single Lesion",9516254,CDM,361,RC,11102,HCPCS,,,facility,both,,,,189,141.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Tangential Biopsy Of Skin (Eg,Shave,Scoop,Saucerize,Curette):Ea Addtl Lesion (Add-On)",9516255,CDM,361,RC,11103,HCPCS,,,facility,both,,,,55,41.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Incisional Biopsy Skin (Eg,Wedge)(Inc Simple Closure):Single Lesion",9516256,CDM,361,RC,11106,HCPCS,,,facility,both,,,,1444,1083,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Incisional Biopsy Skin (Eg,Wedge)(Inc Simple Closure):Single Lesion",9516256,CDM,361,RC,11106,HCPCS,,,facility,both,,,,549,411.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Trancathetr Implant Wireless Pulmon Artery Pressr Sensor,Inc Rt Heart Cath,S&I,Pulmon Artery Angio",9516258,CDM,361,RC,33289,HCPCS,,,facility,both,,,,34034,25525.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Repair, Intermediate, Wounds Face, Ears, Eyelids, Nose, Lips , Mucous Membranes; 12.6-20 Cm",9516262,CDM,361,RC,12055,HCPCS,,,facility,both,,,,1566,1174.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Punch Biopsy Of Skin (Including Simple Closure, When Performed); Single Lesion",9516263,CDM,361,RC,11104,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Punch Biopsy Of Skin (Including Simple Closure, When Performed); Single Lesion",9516263,CDM,361,RC,11104,HCPCS,,,facility,both,,,,363,272.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Punch Biopsy Of Skin (Including Simple Closure, When Performed); Each Separate/Addlesion",9516264,CDM,361,RC,11105,HCPCS,,,facility,both,,,,268,201,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Punch Biopsy Of Skin (Including Simple Closure, When Performed); Each Separate/Addlesion",9516264,CDM,361,RC,11105,HCPCS,,,facility,both,,,,61,45.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Elect Analysis Impl Brain, Sc, Or Periphl Stim Device With Cranial Nerve Stim Program - Simple",9516267,CDM,920,RC,95976,HCPCS,,,facility,both,,,,40,30,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Elect Analysis Impl Brain, Sc, Or Periphl Stim Device With Cranial Nerve Stim Program - Complex",9516268,CDM,920,RC,95977,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Transcatheter Mitral Valve Repair,Percutaneous,Inc Transseptal Puncture:Initial Prosthesis",9516283,CDM,481,RC,33418,HCPCS,,,facility,both,,,,37015,27761.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Transcatheter Mitral Valve Repair,Percutaneous,Inc Transseptal Puncture:Additional Prosthesis",9516284,CDM,481,RC,33419,HCPCS,,,facility,both,,,,3702,2776.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Introduction Of Needle Or Intracatheter,Vein",9516285,CDM,761,RC,36000,HCPCS,,,facility,both,,,,53,39.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Mri Cad Breast,9516288,CDM,610,RC,C8937,HCPCS,,,facility,both,,,,151,113.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Closed Tx Of Proximal Fibula Or Shaft Fracture; W Manipulation,9516290,CDM,361,RC,27781,HCPCS,,,facility,both,,,,2438,1828.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Drainage Of Abscess Of Palate, Uvula",9516295,CDM,361,RC,42000,HCPCS,,,facility,both,,,,666,499.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Cont Gluc Monitoring Patient Provided Equipment,9516304,CDM,920,RC,95249,HCPCS,,,facility,both,,,,144,108,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Cautery Of Cervix; Electro Or Thermal,9516310,CDM,361,RC,57180,HCPCS,,,facility,both,,,,697,522.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Bx Low Leg Soft Tissue,Superficial - 27613",9516311,CDM,361,RC,27613,HCPCS,,,facility,both,,,,3677,2757.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Bx Low Leg Soft Tissue,Deep - 27614",9516312,CDM,361,RC,27614,HCPCS,,,facility,both,,,,6184,4638,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Biopsy Soft Tissue Back/Flank Superficial,9516314,CDM,361,RC,21920,HCPCS,,,facility,both,,,,4311,3233.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Biopsy Soft Tissue Back/Flank Deep,9516315,CDM,361,RC,21925,HCPCS,,,facility,both,,,,6860,5145,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Psychiatric Dx Eval W/Med Svs,9516316,CDM,900,RC,90792,HCPCS,,,facility,both,,,,141,105.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Psychiatric Dx Eval W/Med Svs,9516316,CDM,900,RC,90792,HCPCS,,,facility,both,,,,544,408,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Program Device Eval (In Person) Iterative Adjustment Implant Dual Lead Def System,Analysis",9516318,CDM,480,RC,93283,HCPCS,,,facility,both,,,,173,129.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Unlisted Skin And Subq Tissue Procedure,9516321,CDM,361,RC,17999,HCPCS,,,facility,both,,,,267,200.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Biopsy, Vestibule Of Mouth",9516322,CDM,361,RC,40808,HCPCS,,,facility,both,,,,474,355.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Correct Finger Deformity,9516326,CDM,361,RC,26567,HCPCS,,,facility,both,,,,13082,9811.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Ed-Egd Flexible Foreign Body Removal,9516330,CDM,450,RC,43247,HCPCS,,,facility,both,,,,2696,2022,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Tx Of Femoral Shaft Fracture, W Manipulation, W Wo Skin Or Skeletal Traction",9516331,CDM,361,RC,27502,HCPCS,,,facility,both,,,,1786,1339.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Simple Repair Of  Wounds Of Face, Ears, Eyelids, Nose, Lips, Mucous Membranes; 20.1-30 Cm",9516340,CDM,361,RC,12017,HCPCS,,,facility,both,,,,897,672.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"Hc Inj,Anesthetic Agent/Steroid:Nerves Genicular Nerve Branches Inc Imaging Guidance",9516348,CDM,361,RC,64454,HCPCS,,,facility,both,,,,2929,2196.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Inj,Anesthetic Agent/Steroid:Nerves Genicular Nerve Branches Inc Imaging Guidance",9516348,CDM,361,RC,64454,HCPCS,,,facility,both,,,,2929,2196.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Pericardial Drainage W/Insert Indwell Catheter,Percutaneous, Inc Fluor/Us Guidance 6 Yrs And Older",9516352,CDM,361,RC,33017,HCPCS,,,facility,both,,,,1466,1099.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Radiologic Exam Esophagus Double Contrast Study,9516355,CDM,320,RC,74221,HCPCS,,,facility,both,,,,552,414,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Radiologic Small Intestine Follow-Through Study, Including Multiple Serial Images",9516356,CDM,320,RC,74248,HCPCS,,,facility,both,,,,308,231,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,9516367,CDM,480,RC,93356,HCPCS,,,facility,both,,,,622,466.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std,9516368,CDM,921,RC,93985,HCPCS,,,facility,both,,,,1200,900,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std,9516368,CDM,921,RC,93985,HCPCS,,,facility,both,,,,483,362.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Duplex Scan Artl Infl&Ven O/F Hem Compl Uni Std,9516369,CDM,921,RC,93986,HCPCS,,,facility,both,,,,245,183.75,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
Hc Diagnostic Lumbar Spinal Puncture W/Fluor Or Ct,9516371,CDM,361,RC,62328,HCPCS,,,facility,both,,,,2530,1897.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Therapeutic Spinal Pnxr Drainage Csf W/Fluor/Ct,9516372,CDM,361,RC,62329,HCPCS,,,facility,both,,,,1558,1168.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Eeg Cont Rec W/Video By Tech Min 8 Channels,9516373,CDM,740,RC,95700,HCPCS,,,facility,both,,,,1138,853.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Eeg W/O Video By Tech 2-12 Hr Unmonitored,9516374,CDM,740,RC,95705,HCPCS,,,facility,both,,,,1272,954,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Eeg W/O Video By Tech 2-12Hr Continuous R-T Mntr,9516376,CDM,740,RC,95707,HCPCS,,,facility,both,,,,3372,2529,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Eeg W/O Vid By Tech Ea Incr 12-26Hr Unmonitored,9516377,CDM,740,RC,95708,HCPCS,,,facility,both,,,,1850,1387.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,9516379,CDM,740,RC,95710,HCPCS,,,facility,both,,,,3872,2904,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Veeg By Tech 2-12 Hours Unmonitored,9516380,CDM,740,RC,95711,HCPCS,,,facility,both,,,,1306,979.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Veeg By Tech 2-12 Hr Intermittent Monitoring,9516381,CDM,740,RC,95712,HCPCS,,,facility,both,,,,3072,2304,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Veeg By Tech 2-12 Hr Continuous R-T Monitoring,9516382,CDM,740,RC,95713,HCPCS,,,facility,both,,,,3572,2679,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Veeg By Tech Ea Incr 12-26 Hr Unmonitored,9516383,CDM,740,RC,95714,HCPCS,,,facility,both,,,,2386,1789.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Veeg By Tech Ea Incr 12-26 Hr Intermittent Mntr,9516384,CDM,740,RC,95715,HCPCS,,,facility,both,,,,3572,2679,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Veeg By Tech Ea Incr 12-26 Hr Cont R-T Mntr,9516385,CDM,740,RC,95716,HCPCS,,,facility,both,,,,4072,3054,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Therap Injection Carpal Tunnel,9516386,CDM,361,RC,20526,HCPCS,,,facility,both,,,,274,205.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Reprogramming Of Csf Shunt,9516387,CDM,361,RC,62252,HCPCS,,,facility,both,,,,661,495.75,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Elec Alys Implt Brn Npgt Prgrmg 1St 15 Min,9516388,CDM,361,RC,95983,HCPCS,,,facility,both,,,,106,79.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
C Simple Repair F/E/E/N/L/M 12.6Cm-20.0 Cm,9516396,CDM,361,RC,12016,HCPCS,,,facility,both,,,,860,645,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Ot-Ther Ivntj Cog Funcj Cntct 1St 15 Minutes,9516400,CDM,430,RC,97129,HCPCS,,,facility,both,,,,133,99.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St-Ther Ivntj Cog Funcj Cntct 1St 15 Minutes,9516401,CDM,440,RC,97129,HCPCS,,,facility,both,,,,133,99.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Ot-Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes,9516402,CDM,430,RC,97130,HCPCS,,,facility,both,,,,133,99.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St-Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes,9516403,CDM,440,RC,97130,HCPCS,,,facility,both,,,,112,84,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Adj Tiss Xfer Lid,Nos,Ear Less Than 10Sqcm",9516404,CDM,361,RC,14060,HCPCS,,,facility,both,,,,2064,1548,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Adj Tiss Xfer Lid,Nos,Ear Less Than 10Sqcm",9516404,CDM,361,RC,14060,HCPCS,,,facility,both,,,,3512,2634,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Biopsy Intranasal,9516417,CDM,361,RC,30100,HCPCS,,,facility,both,,,,1454,1090.5,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Closed Rx Shldr Disloc,Prox Hum Fx",9516434,CDM,361,RC,23675,HCPCS,,,facility,both,,,,1898,1423.5,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C Closed Rx Metatarsal Fx,Manip",9516436,CDM,361,RC,28475,HCPCS,,,facility,both,,,,568,426,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Rpr Lip Full Thickness Vermilion,9516441,CDM,361,RC,40650,HCPCS,,,facility,both,,,,1451,1088.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
Hc Thoracentesis Needle/Cath Pleura W/Imaging,9516444,CDM,361,RC,32555,HCPCS,,,facility,both,,,,2128,1596,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Abdominal Paracentesis (Diagnostic Or Therapeutic); With Imaging Guidance,9516445,CDM,361,RC,49083,HCPCS,,,facility,both,,,,2486,1864.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Closed Rx Radio-Ulna Dislocation,9516446,CDM,361,RC,25675,HCPCS,,,facility,both,,,,568,426,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
"C  Placement Of Soft Tissue Localization Device(S),Percutaneous,Including Imaging Guidance;1St Lesio",9516447,CDM,361,RC,10035,HCPCS,,,facility,both,,,,2140,1605,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Any Vessel,W/Intravascular Lithotripsy Inc Angioplasty Within Same Vessel",9516450,CDM,481,RC,C9764,HCPCS,,,facility,both,,,,21482,16111.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Any Vessel,W/Intravascular Lithotripsy And Stent Placement Inc Angioplasty Withi",9516451,CDM,481,RC,C9765,HCPCS,,,facility,both,,,,42338,31753.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Any Vessel,W/Intravascular Lithotripsy And Atherectomy Inc Angioplasty Within Sa",9516452,CDM,481,RC,C9766,HCPCS,,,facility,both,,,,42338,31753.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Revascularization,Any Vessel,W/Intravascular Lithotripsy Stent Placement And Atherectomy Inc Angio",9516453,CDM,481,RC,C9767,HCPCS,,,facility,both,,,,42365,31773.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Health Behavior Assessment, Or Re-Assessment (Ie, Health-Focused Clinical Interview, Behavioral Ob",9516455,CDM,914,RC,96156,HCPCS,,,facility,both,,,,87,65.25,,,,,,,,,,Gross Charge Type: Fsc Pbb Tech 1080002 Unit Charge
"C Health Behavior Intervention, Individual, Face-To-Face; Initial 30 Minutes",9516456,CDM,914,RC,96158,HCPCS,,,facility,both,,,,198,148.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"C Health Behavior Intervention, Individual, Face-To-Face; Each Additional 15 Minutes (List Separatel",9516457,CDM,914,RC,96159,HCPCS,,,facility,both,,,,41,30.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Closed Tx Ulnar Shaft Fracture W/Manipulation,9516473,CDM,361,RC,25535,HCPCS,,,facility,both,,,,743,557.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Repair Intermediate S/A/T/E 20.1-30.0 Cm,9516477,CDM,361,RC,12036,HCPCS,,,facility,both,,,,1380,1035,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Lunate Dislocation W/Manipulation,9516478,CDM,361,RC,25690,HCPCS,,,facility,both,,,,5695,4271.25,,,,,,,,,,Gross Charge Type: Fsc Ed Tech 1080000 Unit Charge
C Closed Tx Lunate Dislocation W/Manipulation,9516478,CDM,361,RC,25690,HCPCS,,,facility,both,,,,5695,4271.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Pt-Adl Training-15 Min,951981,CDM,420,RC,97535,HCPCS,,,facility,both,,,,107,80.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C St-Assessment Of Aphasia,951985,CDM,440,RC,96105,HCPCS,,,facility,both,,,,329,246.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
"Hc Care Manage Beh Svs, At Least 20 Minutes Of Psychologist, Social Worker, Mental Health Counselor,",960G032301,CDM,960,RC,G0323,HCPCS,,,facility,both,,,,75,56.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
HALOPERIDOL 0.5 MG TABS,9662,CDM,250,RC,51079073320,NDC,,,facility,both,2,UN,,4.45,3.34,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 0.5 MG TABS,9662,CDM,250,RC,51079073320,NDC,,,facility,both,3,UN,,3.18,2.39,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 0.5 MG TABS,9662,CDM,250,RC,51079073320,NDC,,,facility,both,4,UN,,2.55,1.91,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 0.5 MG TABS,9662,CDM,250,RC,51079073320,NDC,,,facility,both,6,UN,,1.9,1.42,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 0.5 MG TABS,9662,CDM,250,RC,51079073320,NDC,,,facility,both,10,UN,,1.38,1.03,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 0.5 MG TABS,9662,CDM,250,RC,51079073320,NDC,,,facility,both,1,UN,,6.93,5.2,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG TABS,9665,CDM,250,RC,51079073520,NDC,,,facility,both,0.5,UN,,7.8,5.85,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG TABS,9665,CDM,250,RC,51079073520,NDC,,,facility,both,1.25,UN,,4.6,3.45,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG TABS,9665,CDM,250,RC,51079073520,NDC,,,facility,both,2.5,UN,,3.57,2.67,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG TABS,9665,CDM,250,RC,51079073520,NDC,,,facility,both,3,UN,,3.77,2.82,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG TABS,9665,CDM,250,RC,51079073520,NDC,,,facility,both,1,UN,,8.85,6.64,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG TABS,9665,CDM,250,RC,51079073520,NDC,,,facility,both,2,UN,,5.05,3.79,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,904678261,NDC,,,facility,both,0.5,UN,,8.35,6.26,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,904678261,NDC,,,facility,both,1,UN,,9.25,6.94,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,51079073620,NDC,,,facility,both,0.5,UN,,8.6,6.45,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,904678261,NDC,,,facility,both,3,UN,,4.13,3.1,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,51079073620,NDC,,,facility,both,3,UN,,4.47,3.35,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,51079073620,NDC,,,facility,both,1,UN,,9.65,7.24,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,904678261,NDC,,,facility,both,2.5,UN,,3.88,2.91,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,904678261,NDC,,,facility,both,2,UN,,5.45,4.09,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,51079073620,NDC,,,facility,both,4,UN,,3.79,2.84,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 5 MG TABS,9667,CDM,250,RC,51079073620,NDC,,,facility,both,2,UN,,5.8,4.35,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML SOLN,9668,CDM,636,RC,J1630,HCPCS,67457042612,NDC,facility,both,5,ME,,28.65,21.49,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML CONC,9669,CDM,250,RC,MHS1ML,HCPCS,121058104,NDC,facility,both,1,ML,,5.6,4.2,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML CONC 120 ML BOTTLE,9669,CDM,250,RC,MHS1ML,HCPCS,121058104,NDC,facility,both,1,ML,,0.43,0.32,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN EFFERVESCENT 325 MG TBEF,9698,CDM,250,RC,16500004019,NDC,,,facility,both,1,UN,,6.45,4.84,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Holter Interp,9859322701,CDM,985,RC,93227,HCPCS,,,facility,both,,,,130,97.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Room Intensive Care,9910004,CDM,200,RC,,,,,facility,both,,,,4414,3310.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Room Newborn,9910020,CDM,171,RC,,,,,facility,both,,,,2288,1716,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Observation Direct Admission,9910041,CDM,762,RC,G0379,HCPCS,,,facility,both,,,,1079,809.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Room Nicu Level 2,9910045,CDM,172,RC,,,,,facility,both,,,,3553,2664.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Room Nicu Level 3,9910047,CDM,173,RC,,,,,facility,both,,,,4895,3671.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Room Nicu Level 4,9910048,CDM,174,RC,,,,,facility,both,,,,6350,4762.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Room Nicu Level 1,9910049,CDM,171,RC,,,,,facility,both,,,,2288,1716,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Observation 1St Hour,9910081,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,79,59.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
C Room Intensive Care-Trauma,9910089,CDM,208,RC,,,,,facility,both,,,,5842,4381.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
AMANTADINE 100 MG CAPS,994,CDM,250,RC,50268006915,NDC,,,facility,both,1,UN,,10.8,8.1,,,,,,,,,,Gross Charge Type: Pharmacy
Hc Elective Hyperbaric Oxygen Therapy,9999918301,CDM,999,RC,99183,HCPCS,,,facility,both,,,,292,219,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Hc Holter Monitor Device Not Returned,9999999926,CDM,999,RC,,,,,facility,both,,,,3275,2456.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Medical Supplies,A4404_A4404_270,CDM,270,RC,A4404,HCPCS,,,facility,both,,,,11.75,8.81,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,A4562M_A4562_274,CDM,274,RC,A4562,HCPCS,,,facility,both,,,,137.92,103.44,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,A4649BAN_A4649_272,CDM,272,RC,A4649,HCPCS,,,facility,both,,,,22.6,16.95,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,A4649ZO_A4649_270,CDM,270,RC,A4649,HCPCS,,,facility,both,,,,137.92,103.44,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,CTH01316_B4087_278,CDM,278,RC,B4087,HCPCS,,,facility,both,,,,430.83,323.12,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Pr Elective Spider Veins 15 Min,ELV01,CDM,999,RC,,,,,facility,both,,,,126,94.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Spider Veins 30 Min,ELV02,CDM,999,RC,,,,,facility,both,,,,200,150,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Spider Veins 45 Min,ELV03,CDM,999,RC,,,,,facility,both,,,,250,187.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Spider Veins 60 Min,ELV04,CDM,999,RC,,,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Sclero Incomplt 1 Vein 15 Min,ELV05,CDM,999,RC,,,,,facility,both,,,,136,102,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Sclero Incomplt 1 Vein 30 Min,ELV06,CDM,999,RC,,,,,facility,both,,,,225,168.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Sclero Incomplt 1 Vein 45 Min,ELV07,CDM,999,RC,,,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Sclero Incomplt 1 Vein 60 Min,ELV08,CDM,999,RC,,,,,facility,both,,,,375,281.25,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Sclero Incomplt 2 Or More Vein 15 Min,ELV09,CDM,999,RC,,,,,facility,both,,,,265,198.75,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Sclero Incomplt 2 Or More Vein 30 Min,ELV10,CDM,999,RC,,,,,facility,both,,,,300,225,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Sclero Incomplt 2 Or More Vein 45 Min,ELV11,CDM,999,RC,,,,,facility,both,,,,350,262.5,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Pr Elective Sclero Incomplt 2 Or More Vein 60 Min,ELV12,CDM,999,RC,,,,,facility,both,,,,400,300,,,,,,,,,,Gross Charge Type: Fsc Tech Default 1080001 Unit Charge
Noncdm Charge Record Medical Supplies,IMP05927_A4562_278,CDM,278,RC,A4562,HCPCS,,,facility,both,,,,170.94,128.2,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,MM002505_A4562_278,CDM,278,RC,A4562,HCPCS,,,facility,both,,,,170.94,128.2,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,MM004209_A4562_278,CDM,278,RC,A4562,HCPCS,,,facility,both,,,,159.93,119.95,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,MM008653_A4562_278,CDM,278,RC,A4562,HCPCS,,,facility,both,,,,170.94,128.2,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,MM008677_271,CDM,271,RC,,,,,facility,both,,,,118.11,88.58,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,MM036514_B4087_278,CDM,278,RC,B4087,HCPCS,,,facility,both,,,,427.61,320.71,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Noncdm Charge Record Medical Supplies,MM046539_A4649_271,CDM,271,RC,A4649,HCPCS,,,facility,both,,,,25.99,19.49,,,,,,,,,,"Gross Charge Type: Fsc Tech Default 1080001 Unit Charge | Price Is variable based on underlying billing methodology - especially, for drug and supply items."
Heart Transplant Or Implant Of Heart Assist System With Mcc,001,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",200234.89,other,200234.89,200234.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",003,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",225966.46,other,72352.53,225966.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",003,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",222472.88,other,72352.53,225966.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",003,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",186484.22,other,72352.53,225966.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",003,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",72352.53,other,72352.53,225966.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",003,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",158945.27,other,72352.53,225966.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",004,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,266281.73,percent of total billed charges,15248.88,266281.73,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",004,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",203572.45,other,15248.88,266281.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",004,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15248.88,other,15248.88,266281.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",011,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38323.08,other,38323.08,38323.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",012,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",68504.97,other,68504.97,68504.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,020,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",62949.17,other,62949.17,62949.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Chemothera,023,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",57864,other,15110,57864,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Chemothera,023,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40576.15,other,15110,57864,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Chemothera,023,MS-DRG,,,,,,,facility,inpatient,,,,,,LifeCenter Northwest,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15110,other,15110,57864,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Chemothera,023,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41957.44,other,15110,57864,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Chemothera,023,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41621.19,other,15110,57864,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,024,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27948.26,other,27948.26,105194.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,024,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",105194.84,other,27948.26,105194.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,025,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,52062.97,percent of total billed charges,31666.16,129976.98,
Craniotomy And Endovascular Intracranial Procedures With Mcc,025,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",129976.98,other,31666.16,129976.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,025,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",63128.61,other,31666.16,129976.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,025,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",61290.4,other,31666.16,129976.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,025,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32490.86,other,31666.16,129976.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,025,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",68221.01,other,31666.16,129976.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,025,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50789.29,other,31666.16,129976.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,025,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32783.81,other,31666.16,129976.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,025,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31666.16,other,31666.16,129976.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,026,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",57025.56,other,21329.1,86079.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,026,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22020.22,other,21329.1,86079.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,026,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44823.39,other,21329.1,86079.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,026,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21329.1,other,21329.1,86079.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,026,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,86079.13,percent of total billed charges,21329.1,86079.13,
Craniotomy And Endovascular Intracranial Procedures With Cc,026,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,69596.64,percent of total billed charges,21329.1,86079.13,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,027,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18267.57,other,18267.57,18462.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,027,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18462.16,other,18267.57,18462.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures With Mcc,028,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26840.39,other,26840.39,89868.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures With Mcc,028,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42256.53,other,26840.39,89868.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures With Mcc,028,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",89868.94,other,26840.39,89868.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures With Mcc,028,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44571.92,other,26840.39,89868.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures With Mcc,028,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39759.11,other,26840.39,89868.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,029,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",63664.46,other,25326.54,63664.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,029,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56228.89,other,25326.54,63664.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,029,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25326.54,other,25326.54,63664.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures Without Cc/Mcc,030,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34923.25,other,34708.29,34923.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Procedures Without Cc/Mcc,030,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34708.29,other,34708.29,34923.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ventricular Shunt Procedures With Mcc,031,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,94215.78,percent of total billed charges,94215.78,94215.78,
Ventricular Shunt Procedures With Cc,032,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,29539.65,percent of total billed charges,16009.78,30457.96,
Ventricular Shunt Procedures With Cc,032,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30457.96,other,16009.78,30457.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ventricular Shunt Procedures With Cc,032,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16009.78,other,16009.78,30457.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Carotid Artery Stent Procedures With Cc,035,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17255.95,other,17255.95,17255.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Carotid Artery Stent Procedures Without Cc/Mcc,036,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14024.14,other,14024.14,14024.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures With Mcc,037,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44851.44,other,24951.22,44851.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures With Mcc,037,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24951.22,other,24951.22,44851.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures With Mcc,037,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37787.9,other,24951.22,44851.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures With Mcc,037,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25391.51,other,24951.22,44851.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures With Cc,038,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28664.29,other,12063.7,28664.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures With Cc,038,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12081.36,other,12063.7,28664.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures With Cc,038,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,27829.63,percent of total billed charges,12063.7,28664.29,
Extracranial Procedures With Cc,038,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24900.49,other,12063.7,28664.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures With Cc,038,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12169.75,other,12063.7,28664.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures With Cc,038,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12063.7,other,12063.7,28664.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures Without Cc/Mcc,039,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8743.09,other,8743.09,33544.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures Without Cc/Mcc,039,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33544.7,other,8743.09,33544.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures Without Cc/Mcc,039,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8826.12,other,8743.09,33544.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures Without Cc/Mcc,039,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22275.88,other,8743.09,33544.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures Without Cc/Mcc,039,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8822.38,other,8743.09,33544.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extracranial Procedures Without Cc/Mcc,039,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8813.52,other,8743.09,33544.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",040,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26543.63,other,26543.63,26543.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",041,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28509.24,other,14778.42,28509.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",041,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14778.42,other,14778.42,28509.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",041,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20822.45,other,14778.42,28509.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",041,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16799.81,other,14778.42,28509.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",042,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,41821.14,percent of total billed charges,41821.14,41821.14,
Spinal Disorders And Injuries With Cc/Mcc,052,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14056.13,other,14056.13,14056.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nervous System Neoplasms With Mcc,054,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25083.82,other,11154.8,25083.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nervous System Neoplasms With Mcc,054,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11154.8,other,11154.8,25083.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nervous System Neoplasms With Mcc,054,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11846.55,other,11154.8,25083.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nervous System Neoplasms With Mcc,054,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11179.3,other,11154.8,25083.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nervous System Neoplasms With Mcc,054,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11259.14,other,11154.8,25083.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nervous System Neoplasms Without Mcc,055,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8330.02,other,8330.02,8330.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders With Mcc,056,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",65875.03,other,17846.18,161845.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders With Mcc,056,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17846.18,other,17846.18,161845.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders With Mcc,056,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,33836.43,percent of total billed charges,17846.18,161845.18,
Degenerative Nervous System Disorders With Mcc,056,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",124735.34,other,17846.18,161845.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders With Mcc,056,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",95877.59,other,17846.18,161845.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders With Mcc,056,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18174.67,other,17846.18,161845.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders With Mcc,056,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",161845.18,other,17846.18,161845.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders Without Mcc,057,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12766.64,other,9873.16,21522.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders Without Mcc,057,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10345.42,other,9873.16,21522.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders Without Mcc,057,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9873.16,other,9873.16,21522.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders Without Mcc,057,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10169.35,other,9873.16,21522.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders Without Mcc,057,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10329.43,other,9873.16,21522.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Degenerative Nervous System Disorders Without Mcc,057,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,21522.59,percent of total billed charges,9873.16,21522.59,
Degenerative Nervous System Disorders Without Mcc,057,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12660.04,other,9873.16,21522.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,059,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9164.19,other,9164.19,9164.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,060,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16486.43,other,6979,27059.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,060,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6979,other,6979,27059.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,060,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12514.4,other,6979,27059.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,060,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,27059.06,percent of total billed charges,6979,27059.06,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",061,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21195.89,other,21195.89,21195.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",062,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15305.53,other,14285.74,29741.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",062,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29354.23,other,14285.74,29741.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",062,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29741.37,other,14285.74,29741.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",062,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14285.74,other,14285.74,29741.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",062,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14314.62,other,14285.74,29741.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",062,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15297.7,other,14285.74,29741.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",063,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,39707.29,percent of total billed charges,25207.61,39707.29,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",063,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28421.95,other,25207.61,39707.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",063,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,35004.34,percent of total billed charges,25207.61,39707.29,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",063,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25207.61,other,25207.61,39707.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",063,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38769.99,other,25207.61,39707.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,27976.58,percent of total billed charges,12759.12,112563.87,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28502.32,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16040.74,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32511.35,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35597.78,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14970.64,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,23956.5,percent of total billed charges,12759.12,112563.87,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29824.4,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15092.46,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12759.12,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13599.3,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14542.75,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,112563.87,percent of total billed charges,12759.12,112563.87,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,064,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15133.64,other,12759.12,112563.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,48358.58,percent of total billed charges,7771.06,56338.15,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9570.32,other,7771.06,56338.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18329.94,other,7771.06,56338.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7822.37,other,7771.06,56338.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,25213.58,percent of total billed charges,7771.06,56338.15,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16534.69,other,7771.06,56338.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7893.49,other,7771.06,56338.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,56338.15,percent of total billed charges,7771.06,56338.15,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8472.02,other,7771.06,56338.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7771.06,other,7771.06,56338.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,21223.91,percent of total billed charges,7771.06,56338.15,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,065,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7914.39,other,7771.06,56338.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,066,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5464.4,other,5464.4,10634.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,066,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10634.66,other,5464.4,10634.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,066,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5715.94,other,5464.4,10634.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cva And Precerebral Occlusion Without Infarction With Mcc,067,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11692.98,other,11692.98,11692.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cva And Precerebral Occlusion Without Infarction Without Mcc,068,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6794.97,other,6794.97,6794.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Transient Ischemia Without Thrombolytic,069,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10834.86,other,6138.71,10834.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Transient Ischemia Without Thrombolytic,069,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6277.94,other,6138.71,10834.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Transient Ischemia Without Thrombolytic,069,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6138.71,other,6138.71,10834.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Transient Ischemia Without Thrombolytic,069,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6375.73,other,6138.71,10834.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Mcc,070,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29803.72,other,11500.96,29803.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Mcc,070,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13467.97,other,11500.96,29803.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Mcc,070,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26250.95,other,11500.96,29803.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Mcc,070,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12902.55,other,11500.96,29803.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Mcc,070,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18812.48,other,11500.96,29803.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Mcc,070,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11500.96,other,11500.96,29803.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Mcc,070,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13424.55,other,11500.96,29803.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Mcc,070,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13571.4,other,11500.96,29803.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Cc,071,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7472.22,other,7162.69,17660.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Cc,071,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7258.1,other,7162.69,17660.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Cc,071,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17660.22,other,7162.69,17660.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Cc,071,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8206.88,other,7162.69,17660.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Cc,071,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8012.2,other,7162.69,17660.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Cc,071,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8317.21,other,7162.69,17660.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders With Cc,071,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7162.69,other,7162.69,17660.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nonspecific Cerebrovascular Disorders Without Cc/Mcc,072,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6134.28,other,6134.28,6134.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,073,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",76769.11,other,11175.59,76769.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,073,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11287.59,other,11175.59,76769.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,073,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22227.12,other,11175.59,76769.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,073,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11175.59,other,11175.59,76769.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,073,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11548.16,other,11175.59,76769.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,074,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,10391.93,percent of total billed charges,5071.3,15174.87,
Cranial And Peripheral Nerve Disorders Without Mcc,074,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5071.3,other,5071.3,15174.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,074,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15174.87,other,5071.3,15174.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,074,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7964.99,other,5071.3,15174.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,074,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7933.54,other,5071.3,15174.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,074,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8834.09,other,5071.3,15174.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Viral Meningitis With Cc/Mcc,075,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27785.63,other,27785.63,27785.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Nontraumatic Stupor And Coma With Mcc,080,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18376.48,other,18376.48,18376.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,082,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18005.52,other,16803,67212.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,082,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38060.38,other,16803,67212.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,082,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16803,other,16803,67212.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,082,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,30656.15,percent of total billed charges,16803,67212.56,
Traumatic Stupor And Coma >1 Hour With Mcc,082,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29817.17,other,16803,67212.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,082,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16961.81,other,16803,67212.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,082,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",67212.56,other,16803,67212.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,083,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10296.16,other,10296.16,10600.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,083,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10402.27,other,10296.16,10600.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,083,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10310.16,other,10296.16,10600.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,083,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10600.85,other,10296.16,10600.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,084,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7114.58,other,7114.58,23314.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,084,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7206.81,other,7114.58,23314.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,084,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,23314.89,percent of total billed charges,7114.58,23314.89,
Traumatic Stupor And Coma <1 Hour With Mcc,085,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19250.02,other,17107.86,32926.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Mcc,085,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32926.22,other,17107.86,32926.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Mcc,085,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17107.86,other,17107.86,32926.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Mcc,085,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28964.22,other,17107.86,32926.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Mcc,085,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17211.32,other,17107.86,32926.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Mcc,085,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17285.02,other,17107.86,32926.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,086,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11378.07,other,3722.59,11378.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,086,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10011.54,other,3722.59,11378.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,086,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9860.26,other,3722.59,11378.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,086,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,3722.59,percent of total billed charges,3722.59,11378.07,
Traumatic Stupor And Coma <1 Hour With Cc,086,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10215.86,other,3722.59,11378.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,086,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10114.71,other,3722.59,11378.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,087,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45958.4,other,6943.46,45958.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,087,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,23339.1,percent of total billed charges,6943.46,45958.4,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,087,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6943.46,other,6943.46,45958.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Mcc,091,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30869.75,other,13394.39,30869.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Mcc,091,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13394.39,other,13394.39,30869.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Mcc,091,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25608.71,other,13394.39,30869.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Mcc,091,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18977.92,other,13394.39,30869.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Mcc,091,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14307,other,13394.39,30869.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Mcc,091,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19296.41,other,13394.39,30869.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Mcc,091,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13559.34,other,13394.39,30869.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Cc,092,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7417.71,other,7417.71,16889.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Cc,092,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16889.48,other,7417.71,16889.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Cc,092,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7748.6,other,7417.71,16889.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Cc,092,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,13811.48,percent of total billed charges,7417.71,16889.48,
Other Disorders Of Nervous System With Cc,092,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8065.22,other,7417.71,16889.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System With Cc,092,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7722.43,other,7417.71,16889.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,093,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,13841.34,percent of total billed charges,6143.6,13841.34,
Other Disorders Of Nervous System Without Cc/Mcc,093,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12910.16,other,6143.6,13841.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,093,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6143.6,other,6143.6,13841.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,093,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7763.25,other,6143.6,13841.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,094,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26926.52,other,26926.52,26926.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,097,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27376.67,other,27376.67,27376.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,098,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33695.23,other,25841.87,33695.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,098,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,25841.87,percent of total billed charges,25841.87,33695.23,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,33674.56,percent of total billed charges,7350.81,42973.92,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7350.81,other,7350.81,42973.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24071.92,other,7350.81,42973.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14822.96,other,7350.81,42973.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,12672.65,percent of total billed charges,7350.81,42973.92,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28478.83,other,7350.81,42973.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8425.47,other,7350.81,42973.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15208.4,other,7350.81,42973.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42973.92,other,7350.81,42973.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14790.46,other,7350.81,42973.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14961.75,other,7350.81,42973.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,20569.69,percent of total billed charges,6941.72,20569.69,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12321.14,other,6941.72,20569.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13291.52,other,6941.72,20569.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7060.16,other,6941.72,20569.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,12249.75,percent of total billed charges,6941.72,20569.69,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15535.04,other,6941.72,20569.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,16898.58,percent of total billed charges,6941.72,20569.69,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,12161.54,percent of total billed charges,6941.72,20569.69,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8197.47,other,6941.72,20569.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7346.9,other,6941.72,20569.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6941.72,other,6941.72,20569.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12731.3,other,6941.72,20569.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6592.31,other,6592.31,27521.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19099.9,other,6592.31,27521.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6641.19,other,6592.31,27521.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,11152.28,percent of total billed charges,6592.31,27521.16,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6830.84,other,6592.31,27521.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,27521.16,percent of total billed charges,6592.31,27521.16,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24142.35,other,6592.31,27521.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,56214.56,percent of total billed charges,56214.56,56214.56,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12123.35,other,6744.92,12123.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6744.92,other,6744.92,12123.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10081.31,other,10081.31,10081.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25134.17,other,25134.17,25134.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,21078.74,percent of total billed charges,6749.2,21078.74,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6749.2,other,6749.2,21078.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41110.41,other,15476.86,41110.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15476.86,other,15476.86,41110.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17042.51,other,15476.86,41110.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15792.71,other,15476.86,41110.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29909.63,other,29909.63,29909.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",48459.35,other,48459.35,48459.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9298.38,other,9298.38,9298.38,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15775.9,other,15775.9,15775.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5872.83,other,5872.83,17596.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11192.88,other,5872.83,17596.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,17596.29,percent of total billed charges,5872.83,17596.29,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5926.28,other,5872.83,17596.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9999.71,other,9999.71,9999.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11486.46,other,11486.46,11486.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10226.16,other,5745.77,15678.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11362.4,other,5745.77,15678.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10512.86,other,5745.77,15678.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,15678.08,percent of total billed charges,5745.77,15678.08,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5745.77,other,5745.77,15678.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17110.19,other,17110.19,17110.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12872.14,other,7356.13,13996.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13996.34,other,7356.13,13996.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7356.13,other,7356.13,13996.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7403.64,other,7356.13,13996.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15713.91,other,7144.78,15713.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8238.1,other,7144.78,15713.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7144.78,other,7144.78,15713.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,16905.1,percent of total billed charges,16905.1,16905.1,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,57963.12,percent of total billed charges,28198.44,114393.55,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",114393.55,other,28198.44,114393.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28198.44,other,28198.44,114393.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",67978.65,other,28198.44,114393.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34967.95,other,28198.44,114393.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35317.63,other,28198.44,114393.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34871.03,other,28198.44,114393.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20066.53,other,18943.93,77588.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51347.77,other,18943.93,77588.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18943.93,other,18943.93,77588.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,41269.79,percent of total billed charges,18943.93,77588.25,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39321.61,other,18943.93,77588.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19139.15,other,18943.93,77588.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,77588.25,percent of total billed charges,18943.93,77588.25,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",48422.04,other,18943.93,77588.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,66646.08,percent of total billed charges,18943.93,77588.25,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19055.21,other,18943.93,77588.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,75161.83,percent of total billed charges,14090.35,75161.83,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38551.38,other,14090.35,75161.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42834.87,other,14090.35,75161.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14228.04,other,14090.35,75161.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,40087.05,percent of total billed charges,14090.35,75161.83,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29337.05,other,14090.35,75161.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34915.89,other,14090.35,75161.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,52676.12,percent of total billed charges,14090.35,75161.83,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14090.35,other,14090.35,75161.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14355.25,other,14090.35,75161.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",90212.57,other,25902.78,90212.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",57286.65,other,25902.78,90212.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30485.48,other,25902.78,90212.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29813.94,other,25902.78,90212.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,25902.78,percent of total billed charges,25902.78,90212.57,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30593.25,other,25902.78,90212.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25489.16,other,13793.11,25489.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13931.04,other,13793.11,25489.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13793.11,other,13793.11,25489.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22757.84,other,22757.84,55039.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,34733.15,percent of total billed charges,22757.84,55039.37,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,55039.37,percent of total billed charges,22757.84,55039.37,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,16926.77,percent of total billed charges,10300.67,28483.22,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10300.67,other,10300.67,28483.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21882.99,other,10300.67,28483.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10629.4,other,10300.67,28483.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20707.56,other,10300.67,28483.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10556.15,other,10300.67,28483.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,17457.73,percent of total billed charges,10300.67,28483.22,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10810.86,other,10300.67,28483.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,28483.22,percent of total billed charges,10300.67,28483.22,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10850.69,other,10300.67,28483.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10743.26,other,10300.67,28483.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,17118.86,percent of total billed charges,6386.33,55775.96,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6767.32,other,6386.33,55775.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14133.59,other,6386.33,55775.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6386.33,other,6386.33,55775.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,55775.96,percent of total billed charges,6386.33,55775.96,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,11743.86,percent of total billed charges,6386.33,55775.96,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6500.42,other,6386.33,55775.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7242.12,other,6386.33,55775.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,21681.38,percent of total billed charges,6356.65,32118.2,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6356.65,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32118.2,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12772.68,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26939.5,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13341.96,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,21931.54,percent of total billed charges,6356.65,32118.2,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10236.95,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21817.31,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13276.86,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12751.92,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12890.16,other,6356.65,32118.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6356.65,other,3293,28363.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23566.39,other,3293,28363.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7635.26,other,3293,28363.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28363.5,other,3293,28363.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3293,other,3293,28363.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10137.95,other,3293,28363.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8275.36,other,3293,28363.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12148.46,other,3293,28363.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36164.11,other,12561.06,48789.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12561.06,other,12561.06,48789.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,21463.4,percent of total billed charges,12561.06,48789.43,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",48789.43,other,12561.06,48789.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12685.39,other,12561.06,48789.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17829.53,other,12561.06,48789.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11911.8,other,8814.15,22871,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22871,other,8814.15,22871,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11998.18,other,8814.15,22871,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11889.8,other,8814.15,22871,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8814.15,other,8814.15,22871,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8571.51,other,7954.34,17766.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7954.34,other,7954.34,17766.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15913.17,other,7954.34,17766.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17766.05,other,7954.34,17766.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13011.25,other,7954.34,17766.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29439.34,other,29439.34,29439.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8115.04,other,8115.04,58007.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",58007.54,other,8115.04,58007.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13695.69,other,8115.04,58007.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11952.63,other,8115.04,58007.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21334.53,other,15923.83,21334.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15923.83,other,15923.83,21334.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14921.2,other,14921.2,24416.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,24416.07,percent of total billed charges,14921.2,24416.07,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,41583.36,percent of total billed charges,5535.89,41583.36,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9966.6,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8904.87,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34343.3,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9395.18,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,30450.34,percent of total billed charges,5535.89,41583.36,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7687.34,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18376.58,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9492,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21023.88,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5535.89,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9384.11,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,14416.36,percent of total billed charges,5535.89,41583.36,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9492,other,5535.89,41583.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,50836.88,percent of total billed charges,7884.46,50836.88,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7884.46,other,7884.46,50836.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16526.74,other,7884.46,50836.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8529.42,other,7884.46,50836.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11746.16,other,7884.46,50836.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20634.25,other,7884.46,50836.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7897.37,other,7884.46,50836.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8964.76,other,7884.46,50836.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7076.09,other,6621.23,7076.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6621.23,other,6621.23,7076.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6756.36,other,6621.23,7076.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13345.18,other,13345.18,13559.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13559.51,other,13345.18,13559.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32265.8,other,9986.45,32265.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12655.49,other,9986.45,32265.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22898.97,other,9986.45,32265.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10087.95,other,9986.45,32265.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,17310.35,percent of total billed charges,9986.45,32265.8,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19772.71,other,9986.45,32265.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10184.23,other,9986.45,32265.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10474.66,other,9986.45,32265.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,12775.45,percent of total billed charges,9986.45,32265.8,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10070.6,other,9986.45,32265.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,25273.55,percent of total billed charges,9986.45,32265.8,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9986.45,other,9986.45,32265.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6800.35,other,6445.4,12455.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6528.94,other,6445.4,12455.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,11735.6,percent of total billed charges,6445.4,12455.97,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12455.97,other,6445.4,12455.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6445.4,other,6445.4,12455.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6567.13,other,6445.4,12455.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15063.62,other,14200.18,33294.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33294.83,other,14200.18,33294.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14214.42,other,14200.18,33294.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20136.73,other,14200.18,33294.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14755.13,other,14200.18,33294.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14200.18,other,14200.18,33294.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14325.37,other,14200.18,33294.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,12762.4,percent of total billed charges,12762.4,23580.06,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23580.06,other,12762.4,23580.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14581.87,other,12762.4,23580.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13031.21,other,13031.21,28233.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28233.24,other,13031.21,28233.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13458.72,other,13031.21,28233.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14098.98,other,13031.21,28233.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14089.9,other,13031.21,28233.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16640.6,other,7778.02,17475.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17475.24,other,7778.02,17475.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8221.67,other,7778.02,17475.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15892.4,other,7778.02,17475.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8293.11,other,7778.02,17475.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7778.02,other,7778.02,17475.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8441.42,other,7778.02,17475.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14583.52,other,11082.28,14583.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11082.28,other,11082.28,14583.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,18907.26,percent of total billed charges,7180.6,18907.26,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16844.84,other,7180.6,18907.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14138.65,other,7180.6,18907.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7180.6,other,7180.6,18907.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,10799.37,percent of total billed charges,7180.6,18907.26,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7483.41,other,7180.6,18907.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12708.03,other,10156.6,12708.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10156.6,other,10156.6,12708.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,21298.2,percent of total billed charges,21298.2,21298.2,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6554.74,other,6554.74,13860.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13860.84,other,6554.74,13860.84,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9487.17,other,7233.04,9966.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9966.5,other,7233.04,9966.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7233.04,other,7233.04,9966.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43871.22,other,43871.22,154218.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",154218.74,other,43871.22,154218.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50504.59,other,43871.22,154218.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",99965.83,other,43871.22,154218.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",52555.8,other,43871.22,154218.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",124671.76,other,43871.22,154218.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29688.38,other,9860.98,1879355.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20072.96,other,9860.98,1879355.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39586.52,other,9860.98,1879355.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20261.62,other,9860.98,1879355.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,30644.35,percent of total billed charges,9860.98,1879355.61,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19490.9,other,9860.98,1879355.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9860.98,other,9860.98,1879355.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1879355.61,other,9860.98,1879355.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,40,,16463.62,percent of total billed charges,9860.98,1879355.61,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19734.76,other,9860.98,1879355.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,58704.59,percent of total billed charges,9860.98,1879355.61,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20206.02,other,9860.98,1879355.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",315147.72,other,74275.55,512077.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",74275.55,other,74275.55,512077.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",512077.66,other,74275.55,512077.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",75068.45,other,75068.45,271085.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",153514.95,other,75068.45,271085.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",120304.46,other,75068.45,271085.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",148320.43,other,75068.45,271085.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",93839.77,other,75068.45,271085.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125491.25,other,75068.45,271085.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",271085.67,other,75068.45,271085.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125753.43,other,51745.66,162858.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51745.66,other,51745.66,162858.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,162858.74,percent of total billed charges,51745.66,162858.74,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,239971.26,percent of total billed charges,56743.74,239971.26,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",82180.53,other,56743.74,239971.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",124212.62,other,56743.74,239971.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",57648.13,other,56743.74,239971.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,133368.16,percent of total billed charges,56743.74,239971.26,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",123753.37,other,56743.74,239971.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56743.74,other,56743.74,239971.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,177240.76,percent of total billed charges,56743.74,239971.26,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",73773.53,other,56743.74,239971.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",90988.85,other,56743.74,239971.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",73697.05,other,56743.74,239971.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",71445.38,other,56743.74,239971.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",98313.88,other,38799.51,138356.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41893.93,other,38799.51,138356.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",80575.36,other,38799.51,138356.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38799.51,other,38799.51,138356.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,138356.2,percent of total billed charges,38799.51,138356.2,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",80706.43,other,38799.51,138356.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39185.89,other,38799.51,138356.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43754.6,other,38799.51,138356.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",87074.47,other,34078.39,87074.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34078.39,other,34078.39,87074.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",87023.72,other,34078.39,87074.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34492.32,other,34078.39,87074.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",122246.86,other,45815.81,122246.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45815.81,other,45815.81,122246.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,32609.86,percent of total billed charges,23515.02,85017.12,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",85017.12,other,23515.02,85017.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23515.02,other,23515.02,85017.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50256.2,other,23515.02,85017.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23754.82,other,23515.02,85017.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,249671.8,percent of total billed charges,185671.18,249671.8,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",185671.18,other,185671.18,249671.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",49537.82,other,49537.82,49537.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",60426.63,other,56051.46,133313.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",133313.49,other,56051.46,133313.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",63051.69,other,56051.46,133313.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",117916.1,other,56051.46,133313.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",60204.12,other,56051.46,133313.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",70051.85,other,56051.46,133313.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",57733,other,56051.46,133313.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56803.42,other,56051.46,133313.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56051.46,other,56051.46,133313.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",93581.35,other,37364.91,203146.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,130446.81,percent of total billed charges,37364.91,203146.88,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",78961.42,other,37364.91,203146.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",125387.36,other,37364.91,203146.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",49711.04,other,37364.91,203146.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",203146.88,other,37364.91,203146.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",76825.6,other,37364.91,203146.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37364.91,other,37364.91,203146.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,137840.77,percent of total billed charges,37364.91,203146.88,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37729.54,other,37364.91,203146.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",113113.52,other,43063.48,113113.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43063.48,other,43063.48,113113.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",88801.75,other,43063.48,113113.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43490.88,other,43063.48,113113.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44324.7,other,43063.48,113113.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43430.41,other,43063.48,113113.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,133341.39,percent of total billed charges,29697.12,163568.82,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31462.98,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",73256.57,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",77982.85,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29697.12,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,102637.52,percent of total billed charges,29697.12,163568.82,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",62093.64,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30047.79,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,163568.82,percent of total billed charges,29697.12,163568.82,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38720.04,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",75810.72,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30325.72,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30674.06,other,29697.12,163568.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36006.42,other,36006.42,36006.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19091.17,other,19091.17,31343.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31343.56,other,19091.17,31343.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23791.58,other,19091.17,31343.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22102.67,other,19091.17,31343.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10540.14,other,10540.14,10540.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25510.38,other,25316.66,39286.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39286.05,other,25316.66,39286.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26531.89,other,25316.66,39286.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25978.17,other,25316.66,39286.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25316.66,other,25316.66,39286.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14960.1,other,14960.1,17243.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16989.72,other,14960.1,17243.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17117.83,other,14960.1,17243.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16999.62,other,14960.1,17243.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17243.74,other,14960.1,17243.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15303.87,other,13729.69,28944.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14042.05,other,13729.69,28944.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28944.25,other,13729.69,28944.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13864.11,other,13729.69,28944.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13729.69,other,13729.69,28944.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",55199.01,other,21805.89,102698.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21824.39,other,21805.89,102698.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44406.81,other,21805.89,102698.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",102698.35,other,21805.89,102698.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21805.89,other,21805.89,102698.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22012.92,other,21805.89,102698.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14942.08,other,14099.4,59969.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18363.38,other,14099.4,59969.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40124.28,other,14099.4,59969.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14108.9,other,14099.4,59969.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,32945.09,percent of total billed charges,14099.4,59969.27,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34216.31,other,14099.4,59969.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14230.55,other,14099.4,59969.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,51181.18,percent of total billed charges,14099.4,59969.27,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17509.4,other,14099.4,59969.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14099.4,other,14099.4,59969.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,59969.27,percent of total billed charges,14099.4,59969.27,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14230.55,other,14099.4,59969.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44883.63,other,18673.03,59092.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,59092.95,percent of total billed charges,18673.03,59092.95,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18673.03,other,18673.03,59092.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33564.26,other,11972.61,57332.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12088.92,other,11972.61,57332.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,57332.15,percent of total billed charges,11972.61,57332.15,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12056.28,other,11972.61,57332.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11972.61,other,11972.61,57332.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",58274.22,other,24527.48,58274.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24527.48,other,24527.48,58274.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50901.74,other,24527.48,58274.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24763.56,other,24527.48,58274.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24980.83,other,24527.48,58274.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18725.2,other,18725.2,47163.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",47163.64,other,18725.2,47163.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19508.5,other,18725.2,47163.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40711.65,other,18725.2,47163.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19144.27,other,18725.2,47163.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,25805.22,percent of total billed charges,18725.2,47163.64,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20300.82,other,18725.2,47163.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18984,other,18725.2,47163.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19144.27,other,18725.2,47163.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13832.03,other,13173.36,79369.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33030.68,other,13173.36,79369.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13517.31,other,13173.36,79369.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27473.21,other,13173.36,79369.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19074.8,other,13173.36,79369.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,79369.97,percent of total billed charges,13173.36,79369.97,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22698.75,other,13173.36,79369.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13305.09,other,13173.36,79369.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13173.36,other,13173.36,79369.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20340.7,other,20340.7,20340.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9966.58,other,9966.58,33551.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33551.5,other,9966.58,33551.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12600.03,other,9966.58,33551.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13654.28,other,9966.58,33551.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14809.73,other,14809.73,28327.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28327.61,other,14809.73,28327.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20977.06,other,14809.73,28327.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",61274.06,other,21259.08,61274.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21259.08,other,21259.08,61274.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24375.42,other,21259.08,61274.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",176841.05,other,115275.89,176841.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,115275.89,percent of total billed charges,115275.89,176841.05,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38880,other,38880,78570.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",78570.14,other,38880,78570.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",134735.52,other,50076.02,134735.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50076.02,other,50076.02,134735.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50145.33,other,50076.02,134735.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",68387.07,other,50076.02,134735.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,32403.97,percent of total billed charges,30573.36,85709.64,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",85709.64,other,30573.36,85709.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30573.36,other,30573.36,85709.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",65106.67,other,30573.36,85709.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30906.84,other,30573.36,85709.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31665.95,other,30573.36,85709.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30598.59,other,30573.36,85709.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30864.08,other,30573.36,85709.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,297071.18,percent of total billed charges,31098.45,297071.18,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40567.34,other,31098.45,297071.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",69598.99,other,31098.45,297071.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",46557.37,other,31098.45,297071.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,56270.46,percent of total billed charges,31098.45,297071.18,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",77839.34,other,31098.45,297071.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37479.96,other,31098.45,297071.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,143222.13,percent of total billed charges,31098.45,297071.18,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",64837.5,other,31098.45,297071.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31098.45,other,31098.45,297071.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",69673.26,other,31098.45,297071.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56187.44,other,25518.34,134110.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",55369.4,other,25518.34,134110.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25518.34,other,25518.34,134110.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",57190.72,other,25518.34,134110.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,134110.97,percent of total billed charges,25518.34,134110.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31706.08,other,25518.34,134110.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38614.4,other,25518.34,134110.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25626.62,other,25518.34,134110.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25767.17,other,25518.34,134110.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19244.04,other,18300.72,45496.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45496.37,other,18300.72,45496.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36936.78,other,18300.72,45496.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18327.66,other,18300.72,45496.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18483.73,other,18300.72,45496.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18300.72,other,18300.72,45496.37,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",61097.93,other,28978.5,132425.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37609.59,other,28978.5,132425.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",132425.52,other,28978.5,132425.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28978.5,other,28978.5,132425.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,96550.29,percent of total billed charges,28978.5,132425.52,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29149.23,other,28978.5,132425.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,79580.67,percent of total billed charges,23944.26,103675.3,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25362.98,other,23944.26,103675.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",48342.82,other,23944.26,103675.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23944.26,other,23944.26,103675.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,54188.1,percent of total billed charges,23944.26,103675.3,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51148.39,other,23944.26,103675.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24157.69,other,23944.26,103675.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",103675.3,other,23944.26,103675.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41082.5,other,23944.26,103675.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24392.19,other,23944.26,103675.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,74394.94,percent of total billed charges,23944.26,103675.3,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,110835.65,percent of total billed charges,51960.21,110835.65,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51960.21,other,51960.21,110835.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",66872.76,other,51960.21,110835.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",108445.14,other,76440.16,108445.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,76440.16,percent of total billed charges,76440.16,108445.14,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",77003.48,other,76440.16,108445.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24613.77,other,23592.96,24613.77,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23592.96,other,23592.96,24613.77,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23896.86,other,23592.96,24613.77,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13519.88,other,11977.46,36337.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26628.44,other,11977.46,36337.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11977.46,other,11977.46,36337.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24457.44,other,11977.46,36337.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15496.18,other,11977.46,36337.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12448.57,other,11977.46,36337.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,36337.55,percent of total billed charges,11977.46,36337.55,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12206.85,other,11977.46,36337.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12085.99,other,11977.46,36337.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14697.36,other,7063.29,15854.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15854.88,other,7063.29,15854.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7083.66,other,7063.29,15854.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13618.25,other,7063.29,15854.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12693.35,other,7063.29,15854.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10517.57,other,7063.29,15854.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7372.52,other,7063.29,15854.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7063.29,other,7063.29,15854.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7129.01,other,7063.29,15854.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12686.56,other,5643.58,13685.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13685.72,other,5643.58,13685.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5643.58,other,5643.58,13685.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10911.76,other,5643.58,13685.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7393.14,other,5643.58,13685.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5665.57,other,5643.58,13685.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14860.4,other,14860.4,29210.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29210.69,other,14860.4,29210.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14902.43,other,14860.4,29210.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20320.99,other,14860.4,29210.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14880.66,other,14860.4,29210.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18334.78,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29318.18,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32575.76,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16084.51,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,30588.84,percent of total billed charges,11203.94,44201.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32292.23,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16250.27,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11203.94,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21445.76,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16412.77,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,44201.29,percent of total billed charges,11203.94,44201.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16462.27,other,11203.94,44201.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9235.04,other,8310.57,29638.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21672.53,other,8310.57,29638.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8310.57,other,8310.57,29638.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,17584.39,percent of total billed charges,8310.57,29638.28,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16310.47,other,8310.57,29638.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8391.47,other,8310.57,29638.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,26900.81,percent of total billed charges,8310.57,29638.28,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8930.44,other,8310.57,29638.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8683.4,other,8310.57,29638.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8350.79,other,8310.57,29638.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,29638.28,percent of total billed charges,8310.57,29638.28,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8391.47,other,8310.57,29638.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19252.45,other,19252.45,19422.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19422.22,other,19252.45,19422.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17576.35,other,11259.49,17576.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11259.49,other,11259.49,17576.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,22871.7,percent of total billed charges,8617.56,29796.76,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10365.36,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9725.4,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26551.67,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29501.85,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9771.08,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18973.04,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9858.56,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12135.8,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8617.56,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19182.34,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9994.06,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9796.08,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,29796.76,percent of total billed charges,8617.56,29796.76,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9871.77,other,8617.56,29796.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6665.17,other,6665.17,13349.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,13349.72,percent of total billed charges,6665.17,13349.72,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12734.73,other,6665.17,13349.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6729.11,other,6665.17,13349.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6936.94,other,6665.17,13349.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6744.35,other,6665.17,13349.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,83749.31,percent of total billed charges,12175.22,83749.31,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12175.22,other,12175.22,83749.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7242.01,other,7242.01,7242.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12888.55,other,11888.12,18456.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11888.12,other,11888.12,18456.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18456.59,other,11888.12,18456.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13550.22,other,11888.12,18456.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16796.5,other,16796.5,16796.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5641.87,other,5641.87,13838.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,13838.61,percent of total billed charges,5641.87,13838.61,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5727.62,other,5641.87,13838.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7250.44,other,5641.87,13838.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5939.91,other,5294.45,5939.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5294.45,other,5294.45,5939.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15536.08,other,8887.28,15536.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8887.28,other,8887.28,15536.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9254.03,other,8887.28,15536.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10771.43,other,5836.28,11053.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5836.28,other,5836.28,11053.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11053.52,other,5836.28,11053.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6050.58,other,5836.28,11053.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6278.9,other,5836.28,11053.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17017.33,other,17017.33,17017.33,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7258.49,other,7258.49,7258.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,27798.07,percent of total billed charges,8949.36,27798.07,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9737.64,other,8949.36,27798.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9176.48,other,8949.36,27798.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17383.8,other,8949.36,27798.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8949.36,other,8949.36,27798.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9552.16,other,8949.36,27798.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9168.88,other,8949.36,27798.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9160.87,other,8949.36,27798.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20457,other,5871.33,20588.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14306.95,other,5871.33,20588.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5871.33,other,5871.33,20588.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10934.92,other,5871.33,20588.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5871.4,other,5871.33,20588.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5926.28,other,5871.33,20588.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9381.25,other,5871.33,20588.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5872.83,other,5871.33,20588.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,20588.03,percent of total billed charges,5871.33,20588.03,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5914.52,other,5871.33,20588.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8171.54,other,8171.54,27347.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,23399.2,percent of total billed charges,8171.54,27347.98,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27347.98,other,8171.54,27347.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7116.7,other,6656.72,39622.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6733.25,other,6656.72,39622.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,16088.56,percent of total billed charges,6656.72,39622.75,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12982.36,other,6656.72,39622.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6656.72,other,6656.72,39622.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,39622.75,percent of total billed charges,6656.72,39622.75,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6989.61,other,6656.72,39622.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6733.25,other,6656.72,39622.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6795.56,other,6656.72,39622.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5727.02,other,5727.02,5727.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16540.46,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35387.63,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15656.34,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30764.16,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15471.12,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,21894.09,percent of total billed charges,6161.78,44402.11,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14362.74,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6161.78,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15647.62,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,44402.11,percent of total billed charges,6161.78,44402.11,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15348.31,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,35879.52,percent of total billed charges,6161.78,44402.11,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16803.04,other,6161.78,44402.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17821.78,other,7441.51,19715.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7441.51,other,7441.51,19715.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14358.01,other,7441.51,19715.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,19715.22,percent of total billed charges,7441.51,19715.22,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7630.66,other,7441.51,19715.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7555.11,other,7441.51,19715.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11545.46,other,11545.46,27820.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27820.43,other,11545.46,27820.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21255.8,other,21255.8,64279.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,47186.74,percent of total billed charges,21255.8,64279.04,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45005.89,other,21255.8,64279.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21695.18,other,21255.8,64279.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,64279.04,percent of total billed charges,21255.8,64279.04,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21512.14,other,21255.8,64279.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,46721.64,percent of total billed charges,13685.59,62794,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14510.42,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37335.94,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40725.98,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13685.59,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,56728.98,percent of total billed charges,13685.59,62794,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29072.14,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13819.45,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34963.21,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13819.45,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22788.96,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13695.99,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,62794,percent of total billed charges,13685.59,62794,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13819.45,other,13685.59,62794,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32861.28,other,30770.74,45604.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45604.97,other,30770.74,45604.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30770.74,other,30770.74,45604.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30781.66,other,30770.74,45604.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22199.02,other,22199.02,22421.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22421.23,other,22199.02,22421.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",81131.09,other,37641.7,82021.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",73393.5,other,37641.7,82021.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37641.7,other,37641.7,82021.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",82021.97,other,37641.7,82021.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38000.89,other,37641.7,82021.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12286.67,other,12286.67,12286.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26057.55,other,26057.55,98225.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",89708.98,other,26057.55,98225.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",98225.42,other,26057.55,98225.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33122.02,other,26057.55,98225.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,34382.31,percent of total billed charges,26057.55,98225.42,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",94345.92,other,26057.55,98225.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",47723.28,other,26057.55,98225.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50092.28,other,26057.55,98225.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33220.93,other,26057.55,98225.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,67892.01,percent of total billed charges,26057.55,98225.42,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33481.47,other,26057.55,98225.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18726.19,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38543.73,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41579.33,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17652.55,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,31970.53,percent of total billed charges,15888.21,54186.09,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36401.31,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18142.88,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15888.21,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",54186.09,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34512.82,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17836.18,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18142.88,other,15888.21,54186.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,43895.04,percent of total billed charges,12606.47,43895.04,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28753.79,other,12606.47,43895.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32160.65,other,12606.47,43895.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12606.47,other,12606.47,43895.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25332.96,other,12606.47,43895.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12792.18,other,12606.47,43895.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,31635.08,percent of total billed charges,12606.47,43895.04,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30357.25,other,12606.47,43895.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21381.25,other,12606.47,43895.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12820.09,other,12606.47,43895.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,29946,percent of total billed charges,12606.47,43895.04,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12711.63,other,12606.47,43895.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,42253.06,percent of total billed charges,42253.06,42253.06,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20871.7,other,20871.7,104111.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",104111.27,other,20871.7,104111.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27696.29,other,20871.7,104111.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11998.05,other,3587,39728.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39728.01,other,3587,39728.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11450.32,other,3587,39728.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32341.33,other,3587,39728.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15789.32,other,3587,39728.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,31115.77,percent of total billed charges,3587,39728.01,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3587,other,3587,39728.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15898.12,other,3587,39728.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,36902.95,percent of total billed charges,3587,39728.01,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14172.61,other,3587,39728.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11980.69,other,11294.1,48357.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29933.8,other,11294.1,48357.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11294.1,other,11294.1,48357.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",48357.54,other,11294.1,48357.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22509.93,other,11294.1,48357.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11324.16,other,11294.1,48357.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11426.71,other,11294.1,48357.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",75296.72,other,12215.97,75296.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12215.97,other,12215.97,75296.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24824.59,other,9145.01,36897.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,36897.45,percent of total billed charges,9145.01,36897.45,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9145.01,other,9145.01,36897.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20327.23,other,20327.23,20327.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28377.32,other,11644.28,28377.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11644.28,other,11644.28,28377.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18797.79,other,11644.28,28377.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13773.21,other,11644.28,28377.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9900.31,other,9900.31,9900.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40081.96,other,40081.96,40081.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10442.9,other,10442.9,10442.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17133.95,other,17133.95,17133.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17841.79,other,17841.79,17841.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11049.64,other,11049.64,11340.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11340.15,other,11049.64,11340.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,24803.63,percent of total billed charges,8569.16,24803.63,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8569.16,other,8569.16,24803.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22093.84,other,22093.84,33379.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,33379.32,percent of total billed charges,22093.84,33379.32,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25854.68,other,13046.76,25854.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13046.76,other,13046.76,25854.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13177.23,other,13046.76,25854.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14999.7,other,10341.09,20737.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10341.09,other,10341.09,20737.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20737.35,other,10341.09,20737.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,66822.4,percent of total billed charges,27839.08,136631.68,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",58361.29,other,27839.08,136631.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27839.08,other,27839.08,136631.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,136631.68,percent of total billed charges,27839.08,136631.68,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40432.27,other,27839.08,136631.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30881.19,other,14955.54,30881.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16490.22,other,14955.54,30881.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15856.05,other,14955.54,30881.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14955.54,other,14955.54,30881.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26153.72,other,9757.79,26153.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20565.24,other,9757.79,26153.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9757.79,other,9757.79,26153.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26006.02,other,12565.29,26006.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12565.29,other,12565.29,26006.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13479.68,other,12565.29,26006.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16317.64,other,6567.97,16317.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7708.78,other,6567.97,16317.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15545.63,other,6567.97,16317.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6567.97,other,6567.97,16317.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6096.54,other,5816.4,6096.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5816.4,other,5816.4,6096.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11279.96,other,11279.96,33373.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33373.26,other,11279.96,33373.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13166.23,other,11279.96,33373.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21403.96,other,11279.96,33373.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,24819.06,percent of total billed charges,11279.96,33373.26,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,40,,21927.94,percent of total billed charges,11279.96,33373.26,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12212.28,other,11279.96,33373.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,16322.34,percent of total billed charges,11279.96,33373.26,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13265.53,other,11279.96,33373.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17195.95,other,8059.05,17195.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15499.05,other,8059.05,17195.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8059.05,other,8059.05,17195.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,9525.48,percent of total billed charges,8059.05,17195.95,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8103.91,other,8059.05,17195.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10762.95,other,10762.95,11513.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,11513.92,percent of total billed charges,10762.95,11513.92,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10594.52,other,10594.52,45363.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,45363.69,percent of total billed charges,10594.52,45363.69,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,39779.45,percent of total billed charges,10594.52,45363.69,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14679.84,other,10594.52,45363.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14831.12,other,10594.52,45363.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9707.69,other,9085.08,38066.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9085.08,other,9085.08,38066.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17363.04,other,9085.08,38066.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9245.42,other,9085.08,38066.49,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,38066.49,percent of total billed charges,9085.08,38066.49,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13364.51,other,13364.51,13364.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,14702.65,percent of total billed charges,13154.37,59685.95,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14923.46,other,13154.37,59685.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24491.96,other,13154.37,59685.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28867.03,other,13154.37,59685.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13154.37,other,13154.37,59685.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27326.05,other,13154.37,59685.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13414.28,other,13154.37,59685.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13984.58,other,13154.37,59685.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,40,,19332.16,percent of total billed charges,13154.37,59685.95,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13312.45,other,13154.37,59685.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,59685.95,percent of total billed charges,13154.37,59685.95,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14789.78,other,13154.37,59685.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14334.27,other,7555.92,71507.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7603.46,other,7555.92,71507.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,13469.35,percent of total billed charges,7555.92,71507.52,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14996.63,other,7555.92,71507.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7630.24,other,7555.92,71507.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,71507.52,percent of total billed charges,7555.92,71507.52,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,40,,12340.37,percent of total billed charges,7555.92,71507.52,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7555.92,other,7555.92,71507.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7675.85,other,7555.92,71507.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10825.66,other,5047.7,10825.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9396.09,other,5047.7,10825.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5047.7,other,5047.7,10825.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30261.92,other,11910.58,30261.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23582.5,other,11910.58,30261.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11910.58,other,11910.58,30261.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8257.61,other,8110.13,16183.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16075.28,other,8110.13,16183.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8110.13,other,8110.13,16183.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16183.27,other,8110.13,16183.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12387.74,other,12387.74,12387.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5005.85,other,5005.85,50503.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,50503.98,percent of total billed charges,5005.85,50503.98,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11925.26,other,5005.85,50503.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7561.36,other,7561.36,14673.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14673.79,other,7561.36,14673.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7566.59,other,7561.36,14673.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,12132.02,percent of total billed charges,5426.93,14026.26,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14026.26,other,5426.93,14026.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5426.93,other,5426.93,14026.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,10357.78,percent of total billed charges,5426.93,14026.26,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10252.97,other,5426.93,14026.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5468.79,other,5426.93,14026.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27148.59,other,3869.18,56056.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10999.44,other,3869.18,56056.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,56056.89,percent of total billed charges,3869.18,56056.89,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14000.53,other,3869.18,56056.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11112.79,other,3869.18,56056.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9186.35,other,3869.18,56056.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,40,,3869.18,percent of total billed charges,3869.18,56056.89,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11034.44,other,3869.18,56056.89,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6355.08,other,5690.77,17339.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15743.67,other,5690.77,17339.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6250.58,other,5690.77,17339.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11965.26,other,5690.77,17339.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6296.4,other,5690.77,17339.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,17339.8,percent of total billed charges,5690.77,17339.8,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5690.77,other,5690.77,17339.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6245.07,other,5690.77,17339.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6433.18,other,5690.77,17339.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,7050.88,percent of total billed charges,4523.89,17666.48,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4812.08,other,4523.89,17666.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10897.39,other,4523.89,17666.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4523.89,other,4523.89,17666.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8609.74,other,4523.89,17666.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17666.48,other,4523.89,17666.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,11800.66,percent of total billed charges,4523.89,17666.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22946.66,other,7860.75,22946.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9710.46,other,7860.75,22946.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19035.3,other,7860.75,22946.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9811.76,other,7860.75,22946.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7860.75,other,7860.75,22946.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,40,,11493.49,percent of total billed charges,7860.75,22946.66,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9728.48,other,7860.75,22946.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,12475.32,percent of total billed charges,7860.75,22946.66,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9747.73,other,7860.75,22946.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,17922.3,percent of total billed charges,2204,17922.3,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6527.72,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12967.48,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6143.96,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,15940.5,percent of total billed charges,2204,17922.3,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11676.17,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6207.85,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,13469.52,percent of total billed charges,2204,17922.3,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13989.32,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6361.43,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2204,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6287.81,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,12082.11,percent of total billed charges,2204,17922.3,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6221.22,other,2204,17922.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15009.36,other,10527.74,33737.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33737.56,other,10527.74,33737.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12096,other,10527.74,33737.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,20949.08,percent of total billed charges,10527.74,33737.56,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20377.84,other,10527.74,33737.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12310.31,other,10527.74,33737.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10527.74,other,10527.74,33737.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12093.42,other,10527.74,33737.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12344.46,other,10527.74,33737.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12328.19,other,10527.74,33737.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,16262.94,percent of total billed charges,7276.78,20377.25,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16826.77,other,7276.78,20377.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18696.41,other,7276.78,20377.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14365.08,other,7276.78,20377.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7332.67,other,7276.78,20377.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20186.5,other,7276.78,20377.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18493.01,other,7276.78,20377.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7276.78,other,7276.78,20377.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,13562.11,percent of total billed charges,7276.78,20377.25,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20377.25,other,7276.78,20377.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,18736,percent of total billed charges,5176.67,25367.2,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5987.79,other,5176.67,25367.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13433.93,other,5176.67,25367.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5207.89,other,5176.67,25367.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5176.67,other,5176.67,25367.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,25367.2,percent of total billed charges,5176.67,25367.2,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34393.28,other,34393.28,34393.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29215.76,other,11414.75,41989.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11414.75,other,11414.75,41989.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24141.03,other,11414.75,41989.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,41989.34,percent of total billed charges,11414.75,41989.34,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11550.37,other,11414.75,41989.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,28034.44,percent of total billed charges,8548.04,28034.44,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25569.12,other,8548.04,28034.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8548.04,other,8548.04,28034.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18092.5,other,8548.04,28034.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,27751.09,percent of total billed charges,8548.04,28034.44,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",173689.04,other,173689.04,173689.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24670.59,other,24670.59,24670.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,46248.7,percent of total billed charges,17259.29,46248.7,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41669.12,other,17259.29,46248.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17259.29,other,17259.29,46248.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,34147.9,percent of total billed charges,17259.29,46248.7,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35249.4,other,17259.29,46248.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17437.15,other,17259.29,46248.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,40188.68,percent of total billed charges,17259.29,46248.7,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17434.65,other,17259.29,46248.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,13846.62,percent of total billed charges,12343.63,45959.27,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13072.09,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27337.79,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13606.14,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,22770.13,percent of total billed charges,12343.63,45959.27,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25288.73,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12405.07,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31497.51,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45959.27,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21112.5,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12343.63,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,31299.3,percent of total billed charges,12343.63,45959.27,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12656.15,other,12343.63,45959.27,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22896.99,other,10059.18,49781.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19868.63,other,10059.18,49781.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10059.18,other,10059.18,49781.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,49781.82,percent of total billed charges,10059.18,49781.82,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26214.65,other,10059.18,49781.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,49329.33,percent of total billed charges,10059.18,49781.82,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,46382.96,percent of total billed charges,10059.18,49781.82,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23690.55,other,23690.55,23690.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29250.63,other,29250.63,29250.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,22691.58,percent of total billed charges,14356.17,34479.14,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31489.69,other,14356.17,34479.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34479.14,other,14356.17,34479.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14384.17,other,14356.17,34479.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,17329.96,percent of total billed charges,14356.17,34479.14,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28747.85,other,14356.17,34479.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14356.17,other,14356.17,34479.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14497.04,other,14356.17,34479.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,17759.24,percent of total billed charges,7953.56,19316.02,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16868.86,other,7953.56,19316.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18197.41,other,7953.56,19316.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7953.56,other,7953.56,19316.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15830.96,other,7953.56,19316.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10156.79,other,7953.56,19316.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19161.01,other,7953.56,19316.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,19316.02,percent of total billed charges,7953.56,19316.02,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,12025.38,percent of total billed charges,7953.56,19316.02,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8021.22,other,7953.56,19316.02,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13230.94,other,12356.93,25917.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25917.07,other,12356.93,25917.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13318.62,other,12356.93,25917.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21917.5,other,12356.93,25917.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12356.93,other,12356.93,25917.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8437.13,other,8437.13,44730.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44730.69,other,8437.13,44730.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14018.75,other,8437.13,44730.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13286.65,other,12423.8,53353.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34067.93,other,12423.8,53353.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13242.71,other,12423.8,53353.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12423.8,other,12423.8,53353.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",53353.18,other,12423.8,53353.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,18078.42,percent of total billed charges,1489.2,18542.85,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5599.98,other,1489.2,18542.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17745.41,other,1489.2,18542.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6698.15,other,1489.2,18542.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,10024.34,percent of total billed charges,1489.2,18542.85,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14461.13,other,1489.2,18542.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,13658.63,percent of total billed charges,1489.2,18542.85,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,1489.2,percent of total billed charges,1489.2,18542.85,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15153.39,other,1489.2,18542.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5725.16,other,1489.2,18542.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11020.06,other,1489.2,18542.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10565,other,1489.2,18542.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,18542.85,percent of total billed charges,1489.2,18542.85,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12862.58,other,5031.45,13875.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13875.6,other,5031.45,13875.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12460.24,other,5031.45,13875.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5031.45,other,5031.45,13875.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,13068.71,percent of total billed charges,5031.45,13875.6,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5109.63,other,5031.45,13875.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,28352.8,percent of total billed charges,1102,64577.55,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",64577.55,other,1102,64577.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13713.27,other,1102,64577.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28848.33,other,1102,64577.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15421.93,other,1102,64577.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23493.75,other,1102,64577.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,1102,percent of total billed charges,1102,64577.55,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19095.4,other,1102,64577.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14955.14,other,7325.38,55364.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7370.63,other,7325.38,55364.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14024.45,other,7325.38,55364.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,55364.69,percent of total billed charges,7325.38,55364.69,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7325.38,other,7325.38,55364.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12613.86,other,5626.87,12613.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9991.3,other,5626.87,12613.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5626.87,other,5626.87,12613.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13013.89,other,12427.7,39702.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36355.43,other,12427.7,39702.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12957.05,other,12427.7,39702.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,25443.17,percent of total billed charges,12427.7,39702.59,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25345.06,other,12427.7,39702.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,39702.59,percent of total billed charges,12427.7,39702.59,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12427.7,other,12427.7,39702.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19287.38,other,8368.24,45516.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14881.2,other,8368.24,45516.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,9566.91,percent of total billed charges,8368.24,45516.48,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45516.48,other,8368.24,45516.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8678.98,other,8368.24,45516.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8368.24,other,8368.24,45516.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8407.18,other,8368.24,45516.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13311.76,other,6284.22,23668.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23668.06,other,6284.22,23668.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7659.63,other,6284.22,23668.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6284.22,other,6284.22,23668.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,11577.17,percent of total billed charges,6284.22,23668.06,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",122209.01,other,122209.01,122209.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",47361.47,other,44682.13,160017.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",160017.47,other,44682.13,160017.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44682.13,other,44682.13,160017.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45650.12,other,44682.13,160017.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45588.37,other,44682.13,160017.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",124756.56,other,34177.68,124756.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",71939.7,other,34177.68,124756.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34177.68,other,34177.68,124756.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34550.81,other,34177.68,124756.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",46203.94,other,46203.94,46203.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",110171.71,other,110171.71,110171.71,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,88812.53,percent of total billed charges,27243.07,88812.53,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",80796.18,other,27243.07,88812.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56584.15,other,27243.07,88812.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27474.7,other,27243.07,88812.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27243.07,other,27243.07,88812.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21115.82,other,21115.82,21115.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,65976.62,percent of total billed charges,32048.54,65976.62,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32048.54,other,32048.54,65976.62,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",46628.69,other,32048.54,65976.62,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42040.91,other,32048.54,65976.62,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,28782.64,percent of total billed charges,9995.25,56632.67,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56632.67,other,9995.25,56632.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45480.12,other,9995.25,56632.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9995.25,other,9995.25,56632.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17098.2,other,9995.25,56632.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31402.24,other,31402.24,31402.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",92889.95,other,21284.58,92889.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21284.58,other,21284.58,92889.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39581.91,other,21284.58,92889.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37747.35,other,21284.58,92889.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25651.44,other,25651.44,74220.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,45026.43,percent of total billed charges,25651.44,74220.42,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",53753.97,other,25651.44,74220.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,74220.42,percent of total billed charges,25651.44,74220.42,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25987.41,other,25651.44,74220.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26531.57,other,25651.44,74220.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26248.67,other,25651.44,74220.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50307.22,other,19787.75,50307.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19814.44,other,19787.75,50307.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41909.23,other,19787.75,50307.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20611.7,other,19787.75,50307.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35030,other,19787.75,50307.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19787.75,other,19787.75,50307.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24602.96,other,24602.96,24602.96,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14958.36,other,14087.45,61744.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14087.45,other,14087.45,61744.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,61744.43,percent of total billed charges,14087.45,61744.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14673.44,other,14087.45,61744.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14109.44,other,14087.45,61744.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14246.06,other,14087.45,61744.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,112423.95,percent of total billed charges,35768.01,112423.95,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35768.01,other,35768.01,112423.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",46233.42,other,22041.88,140010.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22324.68,other,22041.88,140010.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",140010.01,other,22041.88,140010.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22041.88,other,22041.88,140010.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,39467.6,percent of total billed charges,22041.88,140010.01,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22328.7,other,22041.88,140010.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43523.64,other,14937.46,43523.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18269.49,other,14937.46,43523.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38596.9,other,14937.46,43523.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18482.06,other,14937.46,43523.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14937.46,other,14937.46,43523.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40083.19,other,40083.19,40083.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,35962.49,percent of total billed charges,16040.57,43979,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16040.57,other,16040.57,43979,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,43979,percent of total billed charges,16040.57,43979,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16305.88,other,16040.57,43979,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16170.5,other,16040.57,43979,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19072.69,other,9088.81,19072.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9623.1,other,9088.81,19072.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9088.81,other,9088.81,19072.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51001.26,other,25059.82,51001.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25182.01,other,25059.82,51001.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50446.51,other,25059.82,51001.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25059.82,other,25059.82,51001.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17736.56,other,14883.58,17736.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14883.58,other,14883.58,17736.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12686.47,other,12686.47,43970.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21830.14,other,12686.47,43970.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43970.95,other,12686.47,43970.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22055.1,other,12686.47,43970.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21614,other,12686.47,43970.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17433.26,other,12686.47,43970.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21436.59,other,12686.47,43970.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22055.1,other,12686.47,43970.95,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,73475.67,percent of total billed charges,15228.29,89122.97,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16442.75,other,15228.29,89122.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37635.22,other,15228.29,89122.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15510.83,other,15228.29,89122.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31316.33,other,15228.29,89122.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15659.76,other,15228.29,89122.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15638.43,other,15228.29,89122.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",47642.48,other,15228.29,89122.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,89122.97,percent of total billed charges,15228.29,89122.97,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15228.29,other,15228.29,89122.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,44259.54,percent of total billed charges,15228.29,89122.97,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15638.43,other,15228.29,89122.97,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25667.58,other,11981.18,30612.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11981.18,other,11981.18,30612.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,22362.65,percent of total billed charges,11981.18,30612.74,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25061.87,other,11981.18,30612.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12112.46,other,11981.18,30612.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30612.74,other,11981.18,30612.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12220.9,other,11981.18,30612.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18467.97,other,18467.97,34951.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34951.42,other,18467.97,34951.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18502.27,other,18467.97,34951.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",56218.57,other,24826.09,56218.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24826.09,other,24826.09,56218.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38389.82,other,38389.82,38389.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,48750.46,percent of total billed charges,15880.09,48750.46,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15880.09,other,15880.09,48750.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,61012.07,percent of total billed charges,19709.84,61012.07,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19709.84,other,19709.84,61012.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,88051.98,percent of total billed charges,23810.44,88051.98,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",60377.33,other,23810.44,88051.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23810.44,other,23810.44,88051.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,59386.37,percent of total billed charges,23810.44,88051.98,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",46367.08,other,23810.44,88051.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",64586.42,other,23810.44,88051.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26068.44,other,23810.44,88051.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26234.34,other,23810.44,88051.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45109.48,other,17692.05,45109.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17902.95,other,17692.05,45109.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,21760.18,percent of total billed charges,17692.05,45109.48,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35221.24,other,17692.05,45109.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18024.55,other,17692.05,45109.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,31355.57,percent of total billed charges,17692.05,45109.48,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34024.52,other,17692.05,45109.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17692.05,other,17692.05,45109.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18592.6,other,17692.05,45109.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22380.95,other,17692.05,45109.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18051.07,other,17692.05,45109.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14840.66,other,6958.73,176089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28184.62,other,6958.73,176089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6958.73,other,6958.73,176089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,21654.49,percent of total billed charges,6958.73,176089.29,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28001.46,other,6958.73,176089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",176089.29,other,6958.73,176089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",54688.44,other,6958.73,176089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13028.1,other,6958.73,176089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,104653.28,percent of total billed charges,6958.73,176089.29,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14154.6,other,6958.73,176089.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31128.05,other,31128.05,31128.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10817.4,other,10526.8,10817.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10526.8,other,10526.8,10817.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23958.92,other,23958.92,121655.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",121655.14,other,23958.92,121655.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25581.16,other,23958.92,121655.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27574.74,other,11370.54,33252.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11370.54,other,11370.54,33252.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21670.46,other,11370.54,33252.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33252.65,other,11370.54,33252.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,23186.02,percent of total billed charges,23186.02,24079.06,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,24079.06,percent of total billed charges,23186.02,24079.06,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18510.42,other,18510.42,18510.42,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13375.3,other,13265.19,78045.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",78045.65,other,13265.19,78045.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13265.19,other,13265.19,78045.65,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13569.36,other,13569.36,26192.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26192.81,other,13569.36,26192.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11065.34,other,11065.34,21464.21,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21464.21,other,11065.34,21464.21,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11291.16,other,11065.34,21464.21,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27497.41,other,27497.41,27497.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21062.24,other,20384.55,21062.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20384.55,other,20384.55,21062.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29338.68,other,29338.68,29338.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30509.34,other,30509.34,30509.34,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12029.96,other,12029.96,26846.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,26846.46,percent of total billed charges,12029.96,26846.46,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24584.73,other,12029.96,26846.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15722.86,other,15722.86,15722.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",66247.06,other,22890.14,78193.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23369.92,other,22890.14,78193.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",47468.51,other,22890.14,78193.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22890.14,other,22890.14,78193.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",78193.12,other,22890.14,78193.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23604.6,other,22890.14,78193.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15243.87,other,13088.49,30151.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30151.09,other,13088.49,30151.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13088.49,other,13088.49,30151.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15124.33,other,13088.49,30151.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15462.31,other,13088.49,30151.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32256.69,other,11127.84,32256.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11331.67,other,11127.84,32256.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11127.84,other,11127.84,32256.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11754.43,other,11127.84,32256.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",116256.63,other,27198.43,116256.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27198.43,other,27198.43,116256.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15603.2,other,14737.13,29818.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28857.45,other,14737.13,29818.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14737.13,other,14737.13,29818.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29639.62,other,14737.13,29818.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29818.46,other,14737.13,29818.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15030.75,other,14737.13,29818.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14881.93,other,14737.13,29818.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10951.8,other,10951.8,17651.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,17651.92,percent of total billed charges,10951.8,17651.92,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11045.35,other,10951.8,17651.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10951.8,other,10951.8,17651.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23441.25,other,21987.23,23441.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21989.73,other,21987.23,23441.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22914.5,other,21987.23,23441.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21987.23,other,21987.23,23441.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,22386.56,percent of total billed charges,21987.23,23441.25,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22355.78,other,21987.23,23441.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,75505.08,percent of total billed charges,15010.32,75505.08,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16704.85,other,15010.32,75505.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",46646.43,other,15010.32,75505.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15793.7,other,15010.32,75505.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33082.4,other,15010.32,75505.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15889.28,other,15010.32,75505.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,53650.04,percent of total billed charges,15010.32,75505.08,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15010.32,other,15010.32,75505.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16118.27,other,15010.32,75505.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15801.7,other,15010.32,75505.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16118.27,other,15010.32,75505.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8744.78,other,8744.78,10578.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10578.44,other,8744.78,10578.44,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6189.41,other,6181.83,22084.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,14351.28,percent of total billed charges,6181.83,22084.9,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12894.54,other,6181.83,22084.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22084.9,other,6181.83,22084.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6181.83,other,6181.83,22084.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6364.13,other,6181.83,22084.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10115.87,other,10115.87,10115.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13713.17,other,8153.94,27889.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27889.7,other,8153.94,27889.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15402.28,other,8153.94,27889.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8153.94,other,8153.94,27889.7,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7814.38,other,7814.38,8458.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8399.8,other,7814.38,8458.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8458.07,other,7814.38,8458.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6154.05,other,6154.05,6154.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16160.61,other,16160.61,19541.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18564.64,other,16160.61,19541.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19541.06,other,16160.61,19541.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40027.5,other,40027.5,40027.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11800.56,other,11800.56,13050.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12734.44,other,11800.56,13050.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13050.22,other,11800.56,13050.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12118.44,other,11800.56,13050.22,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7925.18,other,7414.54,22386.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22386.64,other,7414.54,22386.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7487.15,other,7414.54,22386.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,17096.84,percent of total billed charges,7414.54,22386.64,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14623.61,other,7414.54,22386.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7429.29,other,7414.54,22386.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14011.61,other,7414.54,22386.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7499.85,other,7414.54,22386.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,18263.89,percent of total billed charges,7414.54,22386.64,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7414.54,other,7414.54,22386.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6407.52,other,6407.52,25475.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22196.64,other,6407.52,25475.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,25475.94,percent of total billed charges,6407.52,25475.94,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9906.25,other,6407.52,25475.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6439.31,other,6439.31,11978.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11978.6,other,6439.31,11978.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11552.6,other,9719.64,11552.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9719.64,other,9719.64,11552.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6717.45,other,6717.45,11119.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11119.08,other,6717.45,11119.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6973.65,other,6717.45,11119.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,8461.1,percent of total billed charges,6717.45,11119.08,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13910.79,other,13910.79,16824.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14017.77,other,13910.79,16824.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16824.36,other,13910.79,16824.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9023.85,other,9023.85,9023.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11872.76,other,11872.76,11872.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",46119.24,other,6655.61,46119.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13162.95,other,6655.61,46119.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6655.61,other,6655.61,46119.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6979.73,other,6655.61,46119.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11568.64,other,11568.64,23648.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23648.99,other,11568.64,23648.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11905.98,other,11568.64,23648.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15692.98,other,15692.98,46264.38,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",46264.38,other,15692.98,46264.38,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16717.19,other,15692.98,46264.38,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27048.68,other,7864.66,41277.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28635.76,other,7864.66,41277.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22358.8,other,7864.66,41277.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,41277.32,percent of total billed charges,7864.66,41277.32,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12857.24,other,7864.66,41277.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7864.66,other,7864.66,41277.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12631.05,other,7864.66,41277.32,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,19170.51,percent of total billed charges,19170.51,19170.51,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21902.18,other,21365.79,33266.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21365.79,other,21365.79,33266.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33266.99,other,21365.79,33266.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22897.13,other,21365.79,33266.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28432.29,other,12856.08,33541.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12856.08,other,12856.08,33541.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26282.91,other,12856.08,33541.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33541.47,other,12856.08,33541.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13378.22,other,12856.08,33541.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20540.35,other,20540.35,21490.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21490.09,other,20540.35,21490.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11075.81,other,11075.81,11075.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16884,other,16884,16884,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7772.54,other,7772.54,7772.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12064.1,other,12064.1,12064.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11474.01,other,11474.01,11474.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11215.41,other,8175.47,12946.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12946.85,other,8175.47,12946.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11330.99,other,8175.47,12946.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9869.5,other,8175.47,12946.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10763.43,other,8175.47,12946.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8175.47,other,8175.47,12946.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,8518.33,percent of total billed charges,5490.12,30180.14,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9447.25,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5490.12,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14351.28,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6879.82,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,8747.12,percent of total billed charges,5490.12,30180.14,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13425.41,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6865.27,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,30180.14,percent of total billed charges,5490.12,30180.14,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15598.17,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7272.99,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7071.23,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9867.8,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6900.82,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,11540.23,percent of total billed charges,5490.12,30180.14,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6940.94,other,5490.12,30180.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11416.12,other,11416.12,11416.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14461.75,other,14461.75,38422.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38422.41,other,14461.75,38422.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22424.05,other,22424.05,22424.05,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20929.9,other,20929.9,20929.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17757.95,other,17757.95,40093.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40093.43,other,17757.95,40093.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11803.65,other,11803.65,29051.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29051.18,other,11803.65,29051.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28066.46,other,26283.07,29171.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26283.07,other,26283.07,29171.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29171.54,other,26283.07,29171.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15113,other,14361.63,35881.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35881.41,other,14361.63,35881.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14362.63,other,14361.63,35881.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29208.6,other,14361.63,35881.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14477.8,other,14361.63,35881.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18353.52,other,14361.63,35881.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25372.5,other,14361.63,35881.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14361.63,other,14361.63,35881.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14957.47,other,14361.63,35881.41,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13934.78,other,13934.78,13934.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21657.5,other,21657.5,21657.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11831.17,other,11831.17,11831.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21858.76,other,21858.76,21858.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13225.11,other,13225.11,73511.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",73511.19,other,13225.11,73511.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,29852.42,percent of total billed charges,13225.11,73511.19,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10601.02,other,10601.02,11143.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11143.92,other,10601.02,11143.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,16254.4,percent of total billed charges,7557.89,24222.56,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7557.89,other,7557.89,24222.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10954.27,other,7557.89,24222.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20691.25,other,7557.89,24222.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10823.3,other,7557.89,24222.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11414.52,other,7557.89,24222.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,24222.56,percent of total billed charges,7557.89,24222.56,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11082.06,other,7557.89,24222.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11347.31,other,6823.7,13373.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12608.12,other,6823.7,13373.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7022.27,other,6823.7,13373.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13373.9,other,6823.7,13373.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6823.7,other,6823.7,13373.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10992.5,other,6823.7,13373.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7058.27,other,6823.7,13373.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8906.86,other,5097.28,13976.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,12986.97,percent of total billed charges,5097.28,13976.11,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,13976.11,percent of total billed charges,5097.28,13976.11,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5097.28,other,5097.28,13976.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,7731.76,percent of total billed charges,5097.28,13976.11,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,33481.74,percent of total billed charges,8792.31,69455.5,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8792.31,other,8792.31,69455.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10000.65,other,8792.31,69455.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40791.65,other,8792.31,69455.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9857.26,other,8792.31,69455.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",69455.5,other,8792.31,69455.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,29459.66,percent of total billed charges,8792.31,69455.5,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10145.5,other,8792.31,69455.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10106.46,other,8792.31,69455.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,19660.6,percent of total billed charges,8792.31,69455.5,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10524.81,other,8792.31,69455.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,26962.86,percent of total billed charges,6125.82,34629.91,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6487.76,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12290.53,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13258.49,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6134.74,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,21511.4,percent of total billed charges,6125.82,34629.91,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11418.22,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6125.82,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34629.91,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16030.67,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,18494.1,percent of total billed charges,6125.82,34629.91,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,7408.5,percent of total billed charges,6125.82,34629.91,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6213.11,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6458.45,other,6125.82,34629.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9042.15,other,9042.15,35306.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25623.32,other,9042.15,35306.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11103.1,other,9042.15,35306.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,17725.57,percent of total billed charges,9042.15,35306.75,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24367.85,other,9042.15,35306.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35306.75,other,9042.15,35306.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14300.6,other,9042.15,35306.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12514.78,other,9042.15,35306.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7976.02,other,7521.98,34300.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,34300.76,percent of total billed charges,7521.98,34300.76,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13631.94,other,7521.98,34300.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12616.63,other,7521.98,34300.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8175.13,other,7521.98,34300.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7521.98,other,7521.98,34300.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9866.48,other,5997.16,9866.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5997.16,other,5997.16,9866.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,61252.8,percent of total billed charges,61252.8,61252.8,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20535.64,other,20535.64,20535.64,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30633.96,other,30633.96,44784.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,44784.56,percent of total billed charges,30633.96,44784.56,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23196.82,other,23196.82,23196.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38566.04,other,13836.15,38566.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13836.15,other,13836.15,38566.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,25561.64,percent of total billed charges,13836.15,38566.04,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28592.55,other,13836.15,38566.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13951.3,other,13836.15,38566.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11194.7,other,11192.3,50999.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,25737.51,percent of total billed charges,11192.3,50999.23,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23408.68,other,11192.3,50999.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50999.23,other,11192.3,50999.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,29066.96,percent of total billed charges,11192.3,50999.23,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11192.3,other,11192.3,50999.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",66156.25,other,19177.06,66156.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19177.06,other,19177.06,66156.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20978.65,other,19177.06,66156.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30108.17,other,10318.01,30108.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10331.4,other,10318.01,30108.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20921.04,other,10318.01,30108.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10325.44,other,10318.01,30108.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10428.69,other,10318.01,30108.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10318.01,other,10318.01,30108.17,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8533.4,other,8064.86,23969.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23969.31,other,8064.86,23969.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8064.86,other,8064.86,23969.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15979.87,other,8064.86,23969.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8136.97,other,8064.86,23969.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8154.74,other,8064.86,23969.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20882.06,other,20882.06,20882.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43772.42,other,21490.64,51798.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51798.55,other,21490.64,51798.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26523.36,other,21490.64,51798.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21490.64,other,21490.64,51798.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28337.28,other,21490.64,51798.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9043.99,other,9043.99,38519.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17740.11,other,9043.99,38519.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,32558.34,percent of total billed charges,9043.99,38519.82,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35142.66,other,9043.99,38519.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,38519.82,percent of total billed charges,9043.99,38519.82,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,18190.78,percent of total billed charges,4394.18,42514.98,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8614.02,other,4394.18,42514.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42514.98,other,4394.18,42514.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11370.02,other,4394.18,42514.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,10415.76,percent of total billed charges,4394.18,42514.98,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22824.85,other,4394.18,42514.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11458.9,other,4394.18,42514.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,11199.72,percent of total billed charges,4394.18,42514.98,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9043.99,other,4394.18,42514.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11669.19,other,4394.18,42514.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,4394.18,percent of total billed charges,4394.18,42514.98,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9803.1,other,4394.18,42514.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11230.52,other,4394.18,42514.98,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8259.5,other,6957.25,20158.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20158.11,other,6957.25,20158.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6996.43,other,6957.25,20158.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,8948.62,percent of total billed charges,6957.25,20158.11,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13266.89,other,6957.25,20158.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6957.25,other,6957.25,20158.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15904.17,other,6957.25,20158.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7270.33,other,6957.25,20158.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,9822.59,percent of total billed charges,6957.25,20158.11,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7139.21,other,6957.25,20158.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,10839.41,percent of total billed charges,6957.25,20158.11,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7068.52,other,6957.25,20158.11,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11470.82,other,4880.07,14731.77,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8966.16,other,4880.07,14731.77,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,14731.77,percent of total billed charges,4880.07,14731.77,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4880.07,other,4880.07,14731.77,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8930.15,other,7924.61,17464.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17464.6,other,7924.61,17464.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9342.65,other,7924.61,17464.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7924.61,other,7924.61,17464.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9064.04,other,7924.61,17464.6,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6247.49,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13688.03,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6326.83,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,17903.01,percent of total billed charges,5802.58,17903.01,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12113.01,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6381.42,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14358.19,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6255.79,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6572.86,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6341.53,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5802.58,other,5802.58,17903.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6169.05,other,6148.05,6258.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6258.25,other,6148.05,6258.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6148.05,other,6148.05,6258.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28070.99,other,8915.19,31293.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12434.92,other,8915.19,31293.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20886.63,other,8915.19,31293.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8915.19,other,8915.19,31293.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31293.35,other,8915.19,31293.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,40,,12862.44,percent of total billed charges,8915.19,31293.35,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11334.49,other,8915.19,31293.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10508.84,other,8915.19,31293.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,22647.81,percent of total billed charges,7946.59,22647.81,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8444.16,other,7946.59,22647.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,16162.44,percent of total billed charges,7946.59,22647.81,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13836.64,other,7946.59,22647.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7946.59,other,7946.59,22647.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13275.26,other,7946.59,22647.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7946.59,other,7946.59,22647.81,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11278.68,other,11278.68,11278.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14656.09,other,14656.09,14792.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14792.57,other,14656.09,14792.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11017.77,other,11017.77,11017.77,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25119.73,other,25119.73,25119.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10805.8,other,6382.92,10805.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6382.92,other,6382.92,10805.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13341.66,other,13341.66,26716.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26716.13,other,13341.66,26716.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13379.46,other,13341.66,26716.13,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21591.62,other,14160,28249.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18670.39,other,14160,28249.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,28249.66,percent of total billed charges,14160,28249.66,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14160,other,14160,28249.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14138.23,other,14138.23,28142.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28142.3,other,14138.23,28142.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27156.8,other,27156.8,27156.8,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37450.92,other,37450.92,37450.92,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4836.28,other,4836.28,4836.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,15741.56,percent of total billed charges,7612.23,15741.56,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7612.23,other,7612.23,15741.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,14009.36,percent of total billed charges,10487.68,16818.72,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16818.72,other,10487.68,16818.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,10487.68,percent of total billed charges,10487.68,16818.72,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14328.17,other,10487.68,16818.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,11830.04,percent of total billed charges,10487.68,16818.72,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13403.66,other,10487.68,16818.72,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,12304.47,percent of total billed charges,10487.68,16818.72,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20695.29,other,4087.65,49356.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20587.88,other,4087.65,49356.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4087.65,other,4087.65,49356.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,49356.1,percent of total billed charges,4087.65,49356.1,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12933.38,other,12933.38,12933.38,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,3203.55,percent of total billed charges,3203.55,10191.09,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9171.98,other,3203.55,10191.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10191.09,other,3203.55,10191.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7408.16,other,3203.55,10191.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,3496.66,percent of total billed charges,3203.55,10191.09,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9681.25,other,3203.55,10191.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15508.19,other,15508.19,15508.19,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,156088.16,percent of total billed charges,22732.75,156088.16,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24304.89,other,22732.75,156088.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22732.75,other,22732.75,156088.16,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,12809.62,percent of total billed charges,12537.35,17022.28,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16730.05,other,12537.35,17022.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,12537.35,percent of total billed charges,12537.35,17022.28,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15894.9,other,12537.35,17022.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,17022.28,percent of total billed charges,12537.35,17022.28,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,15086.88,percent of total billed charges,12537.35,17022.28,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,16353.25,percent of total billed charges,11460,40618.09,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15900.29,other,11460,40618.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,12631.76,percent of total billed charges,11460,40618.09,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13851.3,other,11460,40618.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,18370.9,percent of total billed charges,11460,40618.09,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12440.77,other,11460,40618.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19586.45,other,11460,40618.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,40618.09,percent of total billed charges,11460,40618.09,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11460,other,11460,40618.09,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,18194.06,percent of total billed charges,11460,40618.09,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,26554.33,percent of total billed charges,17262.47,30933.1,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19744.5,other,17262.47,30933.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,17262.47,percent of total billed charges,17262.47,30933.1,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23942.38,other,17262.47,30933.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,30933.1,percent of total billed charges,17262.47,30933.1,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19930,other,17262.47,30933.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,21268.52,percent of total billed charges,17262.47,30933.1,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,26691.85,percent of total billed charges,16219.19,26691.85,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17046.79,other,16219.19,26691.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18940.88,other,16219.19,26691.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,21056.3,percent of total billed charges,16219.19,26691.85,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16219.19,other,16219.19,26691.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,23764.08,percent of total billed charges,16219.19,26691.85,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21264.13,other,16219.19,26691.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,24742.32,percent of total billed charges,16219.19,26691.85,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,15994.52,percent of total billed charges,6012.94,19287.76,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15576.25,other,6012.94,19287.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,12683.12,percent of total billed charges,6012.94,19287.76,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13282.29,other,6012.94,19287.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,18574.48,percent of total billed charges,6012.94,19287.76,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,19287.76,percent of total billed charges,6012.94,19287.76,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12322.04,other,6012.94,19287.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6012.94,other,6012.94,19287.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,15145.66,percent of total billed charges,6012.94,19287.76,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,16545.71,percent of total billed charges,6012.94,19287.76,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11092.5,other,6012.94,19287.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,18641.5,percent of total billed charges,6012.94,19287.76,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,22521.83,percent of total billed charges,7323.95,22521.83,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7323.95,other,7323.95,22521.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16548.89,other,7323.95,22521.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,25715.18,percent of total billed charges,8559,95973.03,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8559,other,8559,95973.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",93079.25,other,8559,95973.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,90944.24,percent of total billed charges,8559,95973.03,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",82118.16,other,8559,95973.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,95973.03,percent of total billed charges,8559,95973.03,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,89872.58,percent of total billed charges,8559,95973.03,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",39842.52,other,8559,95973.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",61413.68,other,8559,95973.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50400,other,8559,95973.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,89962.9,percent of total billed charges,8559,95973.03,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,25731.19,percent of total billed charges,22055.83,41210,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41210,other,22055.83,41210,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29316.28,other,22055.83,41210,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,22055.83,percent of total billed charges,22055.83,41210,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9185.83,other,4329.64,51009.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5706,other,4329.64,51009.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6154,other,4329.64,51009.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,5784.47,percent of total billed charges,4329.64,51009.06,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8680.53,other,4329.64,51009.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,4329.64,percent of total billed charges,4329.64,51009.06,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4800,other,4329.64,51009.06,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,51009.06,percent of total billed charges,4329.64,51009.06,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,4446.25,percent of total billed charges,2769.3,20705.03,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2769.3,other,2769.3,20705.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9510,other,2769.3,20705.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,6786.19,percent of total billed charges,2769.3,20705.03,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14825,other,2769.3,20705.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,14640.4,percent of total billed charges,2769.3,20705.03,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14151.1,other,2769.3,20705.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6600,other,2769.3,20705.03,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,20705.03,percent of total billed charges,2769.3,20705.03,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,4754.12,percent of total billed charges,2119,7410.94,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5609.7,other,2119,7410.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2119,other,2119,7410.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,3651.65,percent of total billed charges,2119,7410.94,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3706.25,other,2119,7410.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,4470.63,percent of total billed charges,2119,7410.94,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,7081.16,percent of total billed charges,2119,7410.94,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5757.16,other,2119,7410.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7410.94,other,2119,7410.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,3334.98,percent of total billed charges,2119,7410.94,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2400,other,2119,7410.94,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,3032,percent of total billed charges,2119,7410.94,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,2628.47,percent of total billed charges,1911.3,3137.75,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1911.3,other,1911.3,3137.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2061.84,other,1911.3,3137.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,1959.56,percent of total billed charges,1911.3,3137.75,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3000.58,other,1911.3,3137.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,2703.41,percent of total billed charges,1911.3,3137.75,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,2989.57,percent of total billed charges,1911.3,3137.75,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2206.87,other,1911.3,3137.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2506,other,1911.3,3137.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2647.22,other,1911.3,3137.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,3134.76,percent of total billed charges,1911.3,3137.75,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,3137.75,percent of total billed charges,1911.3,3137.75,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",2383.75,other,1911.3,3137.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,2621.09,percent of total billed charges,1911.3,3137.75,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15777.69,other,15777.69,15777.69,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14582.57,other,14206.78,16202.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16202.85,other,14206.78,16202.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14206.78,other,14206.78,16202.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,10772.83,percent of total billed charges,10474.07,15874.36,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13929.98,other,10474.07,15874.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15874.36,other,10474.07,15874.36,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,10474.07,percent of total billed charges,10474.07,15874.36,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11691.9,other,9745.13,16353.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,9745.13,percent of total billed charges,9745.13,16353.82,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15310.26,other,9745.13,16353.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14720.57,other,9745.13,16353.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,16353.82,percent of total billed charges,9745.13,16353.82,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,11914.66,percent of total billed charges,3249.67,14827.1,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5607.99,other,3249.67,14827.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8270.85,other,3249.67,14827.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8922.24,other,3249.67,14827.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,9047.52,percent of total billed charges,3249.67,14827.1,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10624.01,other,3249.67,14827.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,11691.05,percent of total billed charges,3249.67,14827.1,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7352,other,3249.67,14827.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3249.67,other,3249.67,14827.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5712.99,other,3249.67,14827.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,7106.9,percent of total billed charges,3249.67,14827.1,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,14827.1,percent of total billed charges,3249.67,14827.1,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9182.5,other,3249.67,14827.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,11012.23,percent of total billed charges,3249.67,14827.1,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,11189.5,percent of total billed charges,3249.67,11189.5,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7605.05,other,3249.67,11189.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8450.06,other,3249.67,11189.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,7161.86,percent of total billed charges,3249.67,11189.5,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9613.07,other,3249.67,11189.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,10909.38,percent of total billed charges,3249.67,11189.5,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,10973.66,percent of total billed charges,3249.67,11189.5,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6721.71,other,3249.67,11189.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9082.93,other,3249.67,11189.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3249.67,other,3249.67,11189.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10230.01,other,3249.67,11189.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,10744.8,percent of total billed charges,3249.67,11189.5,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,5839.14,percent of total billed charges,3249.67,11189.5,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10377.68,other,3249.67,11189.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8028.75,other,3249.67,11189.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,9988.08,percent of total billed charges,3249.67,11189.5,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33713.51,other,16457.68,33713.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16457.68,other,16457.68,33713.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20461.96,other,16457.68,33713.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16667.74,other,16457.68,33713.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16478.52,other,16457.68,33713.51,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,13221.49,percent of total billed charges,9163.81,23250.74,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9740.59,other,9163.81,23250.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23250.74,other,9163.81,23250.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9163.81,other,9163.81,23250.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9195.29,other,9163.81,23250.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9290.05,other,9163.81,23250.74,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10522.2,other,10522.2,10855.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10855.14,other,10522.2,10855.14,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,61271.58,percent of total billed charges,6924.16,61271.58,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13111.93,other,6924.16,61271.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6970.92,other,6924.16,61271.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13672.05,other,6924.16,61271.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6981.37,other,6924.16,61271.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6924.16,other,6924.16,61271.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",49772.7,other,6924.16,61271.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11735.36,other,7568.72,11892.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11892.08,other,7568.72,11892.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7568.72,other,7568.72,11892.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11784.78,other,7568.72,11892.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11892.08,other,7568.72,11892.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16506.31,other,16506.31,16506.31,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7672.87,other,7672.87,7672.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,22535.07,percent of total billed charges,12678.27,22535.07,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12678.27,other,12678.27,22535.07,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32902.69,other,7039.77,66276.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,66276.86,percent of total billed charges,7039.77,66276.86,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7039.77,other,7039.77,66276.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20503.2,other,20503.2,31706.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31706.87,other,20503.2,31706.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18009.78,other,18009.78,47767.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",47767.28,other,18009.78,47767.28,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",44834.1,other,16645.58,44834.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16645.58,other,16645.58,44834.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33088,other,33088,33088,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",48472.76,other,9981.36,48472.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9981.36,other,9981.36,48472.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35432.83,other,12480.39,35432.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12480.39,other,12480.39,35432.83,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",70697.73,other,47344.57,70697.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",47344.57,other,47344.57,70697.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15182.27,other,12522.18,17712.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14489.45,other,12522.18,17712.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,12522.18,percent of total billed charges,12522.18,17712.91,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17712.91,other,12522.18,17712.91,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,12910.02,percent of total billed charges,2438.96,13200.57,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12918.49,other,2438.96,13200.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,2438.96,percent of total billed charges,2438.96,13200.57,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6457,other,2438.96,13200.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,10744.96,percent of total billed charges,2438.96,13200.57,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13200.57,other,2438.96,13200.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7701.3,other,2438.96,13200.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6997.42,other,2438.96,13200.57,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,3671.56,percent of total billed charges,3351.6,9644.75,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9644.75,other,3351.6,9644.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,3543.84,percent of total billed charges,3351.6,9644.75,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7471.8,other,3351.6,9644.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,3351.6,percent of total billed charges,3351.6,9644.75,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6712.5,other,3351.6,9644.75,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,4482.94,percent of total billed charges,3351.6,9644.75,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41023.95,other,41023.95,80183.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",80183.12,other,41023.95,80183.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",41446.7,other,41023.95,80183.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",55619.69,other,41023.95,80183.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15575.04,other,15575.04,15575.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",53811.68,other,53811.68,100624.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",100624.08,other,53811.68,100624.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9699.1,other,9699.1,15004.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15004.86,other,9699.1,15004.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20153.86,other,20153.86,20153.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20153.86,other,20153.86,20153.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21502.54,other,14067.36,23280.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23280.87,other,14067.36,23280.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",22886.64,other,14067.36,23280.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14067.36,other,14067.36,23280.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20655.85,other,14067.36,23280.87,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11990.86,other,11990.86,11990.86,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14232.58,other,9113.02,14232.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9113.02,other,9113.02,14232.58,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9338.42,other,8657.48,16909.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16909.4,other,8657.48,16909.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8657.48,other,8657.48,16909.4,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",57175.52,other,57175.52,57175.52,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,12123.66,percent of total billed charges,9325.11,24508.35,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24508.35,other,9325.11,24508.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24508.35,other,9325.11,24508.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18058.33,other,9325.11,24508.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9325.11,other,9325.11,24508.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,157838.71,percent of total billed charges,6388,206160.63,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",38853.45,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",80149.63,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",89134.48,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36578.75,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,40831.61,percent of total billed charges,6388,206160.63,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",72657.33,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37058.5,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",206160.63,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6388,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",52083.07,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36618.3,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31779.01,other,6388,206160.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16138.76,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42548.5,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15192.78,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,20979.47,percent of total billed charges,10229.96,47105.59,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30076.15,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,41517.69,percent of total billed charges,10229.96,47105.59,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10229.96,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10877.2,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15852.96,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34318.82,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13658.38,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,47105.59,percent of total billed charges,10229.96,47105.59,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13922.72,other,10229.96,47105.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,172909.59,percent of total billed charges,10573.34,172909.59,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",86110.21,other,10573.34,172909.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31856.08,other,10573.34,172909.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,73749.21,percent of total billed charges,10573.34,172909.59,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10573.34,other,10573.34,172909.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32580.67,other,10573.34,172909.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,26969.44,percent of total billed charges,10573.34,172909.59,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24608.31,other,10573.34,172909.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,43680.47,percent of total billed charges,12632.22,43680.47,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30891,other,12632.22,43680.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36266.15,other,12632.22,43680.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15940.4,other,12632.22,43680.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",32109.53,other,12632.22,43680.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,32361.7,percent of total billed charges,12632.22,43680.47,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12632.22,other,12632.22,43680.47,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9795.46,other,9795.46,9795.46,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30828.47,other,13515.07,36307.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13515.07,other,13515.07,36307.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27848.05,other,13515.07,36307.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14063.98,other,13515.07,36307.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23708.75,other,13515.07,36307.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,36307.54,percent of total billed charges,13515.07,36307.54,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13955.57,other,13515.07,36307.54,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7259.4,other,7259.4,31111.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14912.47,other,7259.4,31111.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7844.36,other,7259.4,31111.78,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,31111.78,percent of total billed charges,7259.4,31111.78,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6592.9,other,6592.9,6592.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7551.79,other,7551.79,7551.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7118.82,other,7118.82,7397.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7397.5,other,7118.82,7397.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7192.18,other,7118.82,7397.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21715.63,other,16162.62,21715.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16162.62,other,16162.62,21715.63,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",106983.29,other,6090,137800.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45312.32,other,6090,137800.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,137800.76,percent of total billed charges,6090,137800.76,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",80807.18,other,6090,137800.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",58804.03,other,6090,137800.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,118571.29,percent of total billed charges,6090,137800.76,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,LifeCenter Northwest,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6090,other,6090,137800.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20371.65,other,6090,137800.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",52837.14,other,6090,137800.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",51402.95,other,6090,137800.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,26375.73,percent of total billed charges,13190,47610.08,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15541.99,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23551.22,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31034.34,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33478.52,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14559.5,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,32893.37,percent of total billed charges,13190,47610.08,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29015.49,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14984.39,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,38832.13,percent of total billed charges,13190,47610.08,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19967.85,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23729.1,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14572.4,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,LifeCenter Northwest,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13190,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20371.65,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15210.46,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,34976.77,percent of total billed charges,13190,47610.08,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23402.5,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14654.49,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,47610.08,percent of total billed charges,13190,47610.08,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14962.48,other,13190,47610.08,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,18905.1,percent of total billed charges,5490.12,26621.15,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14007.49,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8547.61,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15223.49,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16422.45,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7845.34,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,13096.77,percent of total billed charges,5490.12,26621.15,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15651.3,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8013.17,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,10902.89,percent of total billed charges,5490.12,26621.15,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,26621.15,percent of total billed charges,5490.12,26621.15,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15936.75,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5490.12,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8253.57,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13517.52,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7941.93,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,16441.2,percent of total billed charges,5490.12,26621.15,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8013.17,other,5490.12,26621.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,8833.23,percent of total billed charges,3103,33528.15,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7392.15,other,3103,33528.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3582,other,3103,33528.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7366.64,other,3103,33528.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3103,other,3103,33528.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5047.8,other,3103,33528.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33015.1,other,3103,33528.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33528.15,other,3103,33528.15,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,11212.43,percent of total billed charges,3882.93,17775.55,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3882.93,other,3882.93,17775.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7927,other,3882.93,17775.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,10305.26,percent of total billed charges,3882.93,17775.55,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10566,other,3882.93,17775.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,17775.55,percent of total billed charges,3882.93,17775.55,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9350.8,other,3882.93,17775.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,16074.76,percent of total billed charges,3882.93,17775.55,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11500.85,other,3882.93,17775.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7842.98,other,3882.93,17775.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9000,other,3882.93,17775.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7051.65,other,3882.93,17775.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,8369.5,percent of total billed charges,3882.93,17775.55,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8473,other,3882.93,17775.55,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4644.64,other,4408,15133.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10428,other,4408,15133.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7269.04,other,4408,15133.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,14209.18,percent of total billed charges,4408,15133.53,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12327,other,4408,15133.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,15133.53,percent of total billed charges,4408,15133.53,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9629.72,other,4408,15133.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5436.1,other,4408,15133.53,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,4408,percent of total billed charges,4408,15133.53,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13022.85,other,4800,513840.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4800,other,4800,513840.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14625.96,other,4800,513840.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16505.25,other,4800,513840.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12467.6,other,4800,513840.18,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,513840.18,percent of total billed charges,4800,513840.18,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13206.45,other,5675.58,19814.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,19814.76,percent of total billed charges,5675.58,19814.76,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,8265.96,percent of total billed charges,5675.58,19814.76,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11384.8,other,5675.58,19814.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6403.95,other,5675.58,19814.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12151.36,other,5675.58,19814.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5675.58,other,5675.58,19814.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14091.24,other,5675.58,19814.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,21911.13,percent of total billed charges,5047.81,30364.66,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7979.66,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5047.81,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9671.4,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10428,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10368.6,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,9765.14,percent of total billed charges,5047.81,30364.66,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11879,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10447.35,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,11918.75,percent of total billed charges,5047.81,30364.66,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6403.95,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,10304.74,percent of total billed charges,5047.81,30364.66,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16470.6,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9830.17,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6212.69,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10789.71,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Mountain Health CO-OP,All Commercial Plans,,77.5,,30364.66,percent of total billed charges,5047.81,30364.66,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,14313.2,percent of total billed charges,5047.81,30364.66,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21366.2,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12000,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10484.2,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,8920.5,percent of total billed charges,5047.81,30364.66,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18436.85,other,5047.81,30364.66,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16119,other,5436.1,28587.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28587.9,other,5436.1,28587.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,15711.55,percent of total billed charges,5436.1,28587.9,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5436.1,other,5436.1,28587.9,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,7252.33,percent of total billed charges,1611.82,18305.88,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18305.88,other,1611.82,18305.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13670.45,other,1611.82,18305.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,9961.14,percent of total billed charges,1611.82,18305.88,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1611.82,other,1611.82,18305.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7082.08,other,1611.82,18305.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4603.22,other,1611.82,18305.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,3912,percent of total billed charges,1611.82,18305.88,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3306,other,1611.82,18305.88,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14124,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4835.7,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13026.18,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,16211.91,percent of total billed charges,3306,53314.23,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13588.5,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13307.78,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,12460.99,percent of total billed charges,3306,53314.23,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",53314.23,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Marketplace Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10493.84,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4610.5,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13499.99,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14160.24,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10994.66,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,4408,percent of total billed charges,3306,53314.23,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3306,other,3306,53314.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,9696.8,percent of total billed charges,3223.8,25240.48,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9536.22,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3676.94,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3223.8,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3582,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6651.62,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,9460.32,percent of total billed charges,3223.8,25240.48,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4641,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6692.23,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,12442.54,percent of total billed charges,3223.8,25240.48,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5651.12,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9925.78,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,First Choice,All Commercial Plans,,86.6,,10916.88,percent of total billed charges,3223.8,25240.48,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10068.4,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6625.81,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4298.2,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6939.9,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25240.48,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6800.38,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,5868,percent of total billed charges,3223.8,25240.48,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6737.77,other,3223.8,25240.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",37180.24,other,14143.49,37180.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14143.49,other,14143.49,37180.24,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14387.79,other,14387.79,14387.79,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",59979.45,other,19962.84,85479.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",19962.84,other,19962.84,85479.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",49783.63,other,19962.84,85479.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",85479.85,other,19962.84,85479.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28446.67,other,19962.84,85479.85,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",137316.5,other,1725,137316.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31269.32,other,1725,137316.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15023.26,other,1725,137316.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",52358.72,other,1725,137316.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",1725,other,1725,137316.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12547.07,other,1725,137316.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15353.7,other,1725,137316.5,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10302.46,other,10302.46,20777.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20777.56,other,10302.46,20777.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16894.08,other,10302.46,20777.56,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11331.39,other,11331.39,11331.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7067.39,other,7067.39,11086.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11086.25,other,7067.39,11086.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7317.31,other,7317.31,18086.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,18086.23,percent of total billed charges,7317.31,18086.23,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13421.5,other,7317.31,18086.23,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,26382.59,percent of total billed charges,5297.73,26382.59,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9846.77,other,5297.73,26382.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5297.73,other,5297.73,26382.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8230,other,5297.73,26382.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",5297.73,other,5297.73,26382.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,27612.81,percent of total billed charges,4408,35838.3,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23417.33,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21556,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12065.8,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,35838.3,percent of total billed charges,4408,35838.3,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18526.78,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12138.38,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15348.48,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27274.43,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",15943.76,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11800.72,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Optum,Behavioral Health Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4408,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12137.15,other,4408,35838.3,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,84656.68,percent of total billed charges,3929.11,84656.68,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7165.37,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12754.8,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6702.73,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,36261.51,percent of total billed charges,3929.11,84656.68,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12449.48,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6405.89,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,18368.83,percent of total billed charges,3929.11,84656.68,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27715.9,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3929.11,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6788.96,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8955.05,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6844.32,other,3929.11,84656.68,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,15848.24,percent of total billed charges,3929.11,84656.68,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29073.01,other,8857.38,29073.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13480.58,other,8857.38,29073.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",27307.56,other,8857.38,29073.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8857.38,other,8857.38,29073.01,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,17406.04,percent of total billed charges,3856,17617.45,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",17617.45,other,3856,17617.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,10670.5,percent of total billed charges,3856,17617.45,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",3856,other,3856,17617.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7944.54,other,3856,17617.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",14327.35,other,11695.67,28154.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28154.1,other,11695.67,28154.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11695.67,other,11695.67,28154.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",16553.25,other,16553.25,16553.25,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,82064.07,percent of total billed charges,82064.07,82064.07,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",43681.73,other,18219.08,43681.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18219.08,other,18219.08,43681.73,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9549.61,other,9257.53,9549.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9257.53,other,9257.53,9549.61,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,33444.29,percent of total billed charges,6338.23,33444.29,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11316.98,other,6338.23,33444.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",6338.23,other,6338.23,33444.29,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,3388.75,percent of total billed charges,3388.75,10406.12,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",8666.07,other,3388.75,10406.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",10406.12,other,3388.75,10406.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",4763.69,other,3388.75,10406.12,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,73031.81,percent of total billed charges,27247.79,77265.04,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",30688.94,other,27247.79,77265.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",28560.75,other,27247.79,77265.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,27247.79,percent of total billed charges,27247.79,77265.04,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",29126.31,other,27247.79,77265.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",77265.04,other,27247.79,77265.04,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",48527.94,other,48527.94,104693.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",104693.67,other,48527.94,104693.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Coordinated Care Corporation,Ambetter Exchange,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",68592.84,other,48527.94,104693.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Kaiser,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",53654.9,other,48527.94,104693.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,72014.92,percent of total billed charges,48527.94,104693.67,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",52331.53,other,48527.94,104693.67,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,83,,70747.15,percent of total billed charges,21370.35,97648.39,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",60865.03,other,21370.35,97648.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Premera All Commercial Plans,,61.8,,41707.81,percent of total billed charges,21370.35,97648.39,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31509.59,other,21370.35,97648.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21370.35,other,21370.35,97648.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,59381.56,percent of total billed charges,21370.35,97648.39,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",97648.39,other,21370.35,97648.39,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42173.45,other,20380.12,42173.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20380.12,other,20380.12,42173.45,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",658949.2,other,21042.14,658949.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",21042.14,other,21042.14,658949.2,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24591.55,other,11041.34,128831.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11429.49,other,11041.34,128831.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicaid Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",128831.76,other,11041.34,128831.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",11041.34,other,11041.34,128831.76,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",9005.92,other,7471.7,29380.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Multiplan,PHCS All Commercial Plans,,80,,29380.48,percent of total billed charges,7471.7,29380.48,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",7471.7,other,7471.7,29380.48,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",54475.26,other,54475.26,54475.26,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",36922.25,other,33953.62,69736.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",34708.9,other,33953.62,69736.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",69736.59,other,33953.62,69736.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45537.56,other,33953.62,69736.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",33953.62,other,33953.62,69736.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",35809.18,other,33953.62,69736.59,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",42006.65,other,5913.26,45314.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",45314.99,other,5913.26,45314.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",26729.95,other,5913.26,45314.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",13168.82,other,5913.26,45314.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,83.1,,5913.26,percent of total billed charges,5913.26,45314.99,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18426.9,other,5913.26,45314.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",18765.54,other,5913.26,45314.99,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12329.43,other,12329.43,12329.43,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",109588.12,other,23376.78,275715.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",24963.53,other,23376.78,275715.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",50946.64,other,23376.78,275715.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",23376.78,other,23376.78,275715.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",25454.81,other,23376.78,275715.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,PacificSource,All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",275715.35,other,23376.78,275715.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",31345.43,other,23376.78,275715.35,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho Medicare Managed Care Plan,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",12588.13,other,12588.13,40052.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Shield,Regence All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",40052.1,other,12588.13,40052.1,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Blue Cross,Idaho All Commercial Plans,,,"Conditional payment logic at the claim level including numerous contracting methods, hierarchical applications, and service utilization requirements.",20374.82,other,20374.82,20374.82,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The estimated allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer鈥檚 algorithm."
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,UnitedHealthCare,All Commercial Plans,,85,,1441.6,percent of total billed charges,1441.6,1441.6,
Professional Component,,,,,,,,,,,,,26,,,Aetna,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Blue Shield,Regence All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Cigna,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,First Choice,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Kaiser,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,LifeCenter Northwest,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Molina,Medicare Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Mountain Health CO-OP,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Multiplan,PHCS All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,Optum,Behavioral Health Plan,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,PacificSource,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,,,,,26,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Aetna,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Blue Shield,Regence All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Cigna,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,First Choice,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Kaiser,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,LifeCenter Northwest,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Molina,Medicare Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Mountain Health CO-OP,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Multiplan,PHCS All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,Optum,Behavioral Health Plan,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,PacificSource,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
Bilateral Procedure,,,,,,,,,,,,,50,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Aetna,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Amerigroup,Wellpoint Medicaid Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Blue Cross,Idaho QHP/QEP Other Commercial Plan,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Blue Shield,Regence All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Cigna,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Coordinated Care Corporation,Medicaid Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,First Choice,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Kaiser,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,LifeCenter Northwest,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Molina,Medicare Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Mountain Health CO-OP,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Multiplan,PHCS All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Northern Idaho Advanced Care Hospital,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,Optum,Behavioral Health Plan,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,PacificSource,All Commercial Plans,,,,,,,,The modified price is presented in the standard charge value.
"Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component cha",,,,,,,,,,,,,TC,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,The modified price is presented in the standard charge value.